2.  /s- y 


Univ.of  III.  Library 

51 


FISTULA,  H2E  MOBBHOID S , £S*v 
PAINFUL  ULCEB, 
STBICTUBE,  PBOLAPSUS 

AND  OTHER 

DISEASES  OF  THE  BECTUM 

THEIR 

DIAGNOSIS  AND  TREATMENT 

BY 

WILLIAM  ALLINGHAM 

FELLOW  OF  THE  ROYAL  COLLEGE  OF  SURGEONS  OF  ENGLAND; 

SURGEON  TO  ST.  MARK’S  HOSPITAL  FOR  FISTULA  AND  OTHER  DISEASES  OF  THE  RECTUM; 

ETC.  ETC.  ETC. 

FOURTH  EDITION 


PHILADELPHIA 
PEESLEY  BLAKISTON 
1882 


Digitized  by  the  Internet  Archive 
in  2017  with  funding  from 

University  of  Illinois  Urbana-Champaign  Alternates 


https://archive.org/details/fistulahmorrhoidOOalli 


PREFACE  TO  THE  FOURTH  EDITION 


That  this  book  has  not  been  written  in  vain  appears 
to  be  evidenced  by  the  facts,  that  three  large  editions 
have  been  sold  in  this  country  and  in  America,  that  it 
has  been  translated  into  the  French,  Italian,  Spanish, 
and  Russian  languages,  and  that  a fourth  edition  is 
now  demanded,  the  third  having  long  been  exhausted. 
An  endeavour  has  been  made  to  remove  obscurities, 
correct  errors,  and  revise  generally,  without  much 
enlarging  the  work.  An  index  is  added,  which  it  is 
hoped  will  facilitate  reference. 


25,  Grosvenor  Street ; 
December , 1881. 


4 

■v 

N>S 


801929 


CONTENTS 


CHAPTER  I 

Introductory.— Statistics,  2,  3. 


CHAPTER  II 

Examination  op  the  Patient,  5. — Exploration  of  the  Rectum,  7 ; 
Use  of  the  Speculum,  8;  Introduction  of  the  Hand,  9 ; Dilatation 
of  the  Sphincters,  10. 


CHAPTER  III 

Fistula  in  Ano,  12. — Causes,  13 ; Abscesses  and  Treatment,  14 — 16  ; 
Use  of  Drainage  Tubes,  17  ; Various  Forms  of  Fistula,  18;  Ex- 
amination of  a Patient  with  Fistula  or  Sinus,  19,  20,  21 ; Dangerous 
kinds  of  Fistulae,  22  ; Treatment  of  Blind  External  Fistula,  23 ; 
Spontaneous  cure  of  Fistula,  24 ; Cases,  25  ; Cure  by  Treatment 
without  Cutting,  26,  27,  28. 


CHAPTER  IV 

Fistula  and  its  Treatment  by  Elastic  Ligature,  29—36. 


CHAPTER  V 

Operations  on  Fistula  in  Ano,  37. — Directions  for  the  Operation, 
38—45  ; Internal  Fistula,  46,  47  ; Causes  of  Incontinence  of  Faeces, 
how  to  avoid,  47 — 49 ; Dressing  and  healing  Wounds  after 
Operating,  49 — 52  ; Treatment  of  difficult  Cases,  53. 


VI 


CONTENTS 


CHAPTER  VI 

Fistula,  in  Conjunction  with  Phthisis,  56. — Opinions  of  Authors, 
58;  Discussion  of  this  Subject,  59 — 64;  Cases,  65;  Question  of 
Cough,  67 ; Treatment  of  Fistulous  Sinuses  in  Consumptive 
Patients,  68 — 72. 


CHAPTER  VII 

Haemorrhoids — Classification,  73. — External  Piles,  Diagnosis, 
Varieties,  and  Treatment,  74 — 82. 

CHAPTER  VIII 

Internal  Haemorrhoids,  83. — Causes,  and  Opinions  of  French 
Authors,  Verneuil’s  Theory  of  Predisposing  Causes,  Discussion, 
84 — 88;  Varieties  of  Internal  Piles,  88;  Structure,  &c.,  90 — 92; 
Question  of  Operating,  93 ; Cases,  96 ; Dangers  resulting  from 
Losses  of  Blood,  97,  98 ; Protrusion  of  Haemorrhoids,  99 — 102 ; 
Cases  best  suited  to  Constitutional  Treatment,  103 ; Connection  of 
Diseases  of  the  Uterus  and  Haemorrhoids,  with  cases,  104 — 107. 

CHAPTER  IX 

Operations  on  Internal  Hemorrhoids  — Eleven  Methods 
described,  109,  110;  Excision  of  Haemorrhoids,  110;  Treatment 
by  the  Ecraseur,  112  ; Application  of  Caustics,  113 ; Injection  of 
Carbolic  Acid,  &c.,  117;  Cauterisation  “ponctuee,”  119;  Cauteri- 
sation “ linear,”  120 ; Operations  by  Galvanic  Cautery,  125 ; 
Removal  of  Haemorrhoids  by  Clamp,  Scissors,  and  Heated  Iron, 
126 ; Dilatation  of  Sphincter  Muscles,  127  ; Treatment  of  Internal 
Haemorrhoids  by  Crushing,  130;  Treatment  of  Internal  Piles  by 
Ligature,  133 ; Author’s  Mode  of  Operating,  134 ; After-Treat- 
ment, 136  ; Question  of  Pain,  138;  Retention  of  Urine,  141 ; Success 
and  Statistics  of  the  Operation,  142;  Exceedingly  small  Mor- 
tality, 143. 


CHAPTER  X 

Complications  of  Hemorrhoids,  146. — Impaction  of  Faeces,  148. 

CHAPTER  XI 

Hemorrhages  after  Operations.— Varieties,  151;  Treatment  and 
Cases,  152—160. 


CONTENTS 


Yll 


CHAPTER  XII 

Procidentia  Recti. — Definition,  Diagnosis,  &c.,  161 ; in  Children, 
163;  in  Adults,  165  ; Permanent  Cure,  167 — 170;  Cases,  170 — 172. 


CHAPTER  XIII 

Polypus  Recti,  173.— Varieties,  174 — 176;  Diagnosis,  177;  Cases, 
178 — 180;  Treatment,  181. 


CHAPTER  XIY 

Pruritus  Ani. — Causes,  182;  Varieties,  184;  Treatment,  185 — 190. 


CHAPTER  XV 

Fissure  and  Painful  Irritable  Ulcer  of  the  Rectum,  191. — 
Diagnosis,  193  ; Connection  with  Uterine  Disease,  195  ; Combined 
with  Polypus,  195 ; Cure  by  Simple  Treatment,  196 ; with  Cases, 
to  200 ; Treatment  by  Division  of  Sphincter  Muscles,  201 ; Method 
of  Operating,  202 ; Nervous  Symptoms  associated  with  Fissure, 
204 — 206 ; Why  are  these  Ulcers  so  Painful  P 207  ; Treatment  by 
complete  Dilatation  of  the  Anus,  209 ; Results,  210,  211. 


CHAPTER  XYI 

Impaction  of  Faeces,  213. — Diagnosis,  Causes,  and  Cases,  213 — 217  ; 
Treatment,  218 ; Concretions  in  the  Rectum,  219. 


CHAPTER  XYII 

Ulceration  and  Stricture  of  the  Rectum,  223.— Symptoms, 
Diagnosis,  223—229  ; Statistics  of  Seventy  Cases  in  Hospital,  230  ; 
Observations  on,  234 — 237  ; Linear  Rectotomy,  257 ; Twenty-nine 
Cases  in  Private  Practice,  239 ; with  Observations,  to  250 ; Causes 
of  Ulceration  and  Stricture  with  reference  to  Syphilis  and  Venereal 
Sores,  251 ; Opinions  of  French,  American,  and  English  Authori- 
ties, 252 — 256;  Treatment,  257—262;  Stricture  of  the  Rectum 
without  Ulceration,  262  ; Treatment,  & c.,  266. 


Vlll 


CONTENTS 


CHAPTER  XVIII 

Cancer  of  the  Recttjm,  269. — Observations  and  Varieties,  270; 
Treatment,  275 ; Chian  Turpentine,  277 ; Operations  for  Relief  or 
Possible  Cure,  277 ; Extirpation,  278  ; Cases — Thirteen  Partial 
Excisions,  Sixteen  Complete,  by  the  Author,  280—293  ; Criticism 
on  the  Operation,  294  ; Colotomy  in  Cancer,  Thirty-nine  Cases  by 
the  Author,  299  ; Mode  of  Performing  Colotomy,  299—307. 


CHAPTER  XIX 

Rodent  or  Lupoid  Ulcer,  308. — Diagnosis,  309;  Treatment,  310; 
Cases,  311 — 315. 


CHAPTER  XX 

Villous  Tumour  of  the  Rectum,  316. — Description,  317 ; Cases, 
318—322. 


CHAPTER  XXI 

Miscellaneous,  323. — Neuralgia  of  the  Rectum,  323;  Removal  of 
Coccyx,  325 ; Inflammation  of  the  Rectum,  327. 


CHAPTER  I 


INTRODUCTORY 

Rectal  diseases  are  among  the  most  common  that 
affect  civilised  humanity.  They  are  of  rare  occurrence 
in  barbarous  countries.  From  information  obtained 
when  travelling  in  South  Africa,  I have  reason  to 
believe  that  the  natives  of  that  part  of  the  world  very 
seldom  suffer  from  these  affections,  but  some  of  my 
medical  friends  practising  in  India,  and  also  in  China, 
have  informed  me  that  the  natives  of  those  countries 
are  not  exempt,  and  that  severe  cases  of  various  kinds 
of  rectal  disease  are  not  uncommon.  The  native  doc- 
tors treat  bleeding  piles  by  thrusting  red-hot  skewers 
into  the  centre  of  each  tumour.  It  is  curious  that  a 
somewhat  similar  plan  has  been  recently  advocated  by 
a London  surgeon.  Food  and  alcohol,  sedentary  in- 
door occupations,  and  defects  in  clothing,  have  much 
influence  in  the  causation  of  these  maladies,  which, 
though  not  actually  dangerous  to  life,  certainly  give 
rise  to  a vast  amount  of  suffering,  by  which  I mean 
not  only  pain,  but  also  the  distress  arising  from  inabi- 
lity to  work  for  daily  bread.  Both  laborious  and 
sedentary  occupations  are  often  rendered  almost  unen- 
durable. 

It  is  true  that  the  majority  of  these  affections  are 


2 


INTRODUCTORY 


very  amenable  to  proper  treatment ; the  amount  of 
benefit  that  can  be  conferred  by  a well-skilled  surgeon 
is  really  remarkable,  but  there  is  the  opposite  proposi- 
tion to  be  considered.  When  diseases  of  the  rectum 
are  neglected,  or  when  the  surgeon  prescribes  confec- 
tion of  senna  and  gall-ointment  in  every  case,  cures  do 
not  frequently  result. 

An  accurate  diagnosis  in  rectal  diseases  is  all- 
important,  and  to  prescribe  for  patients  suffering  from 
these  maladies,  without  examining  them  both  ocu- 
larly and  digitally,  is  not  only  false  delicacy,  but 
radically  wrong,  and  likely  to  bring  the  treatment  of 
these  diseases  into  contempt. 

It  still  constantly  occurs  to  me  to  see  patients  who 
have  been  for  a long  time  under  treatment  by  qualified 
practitioners,  and  to  whom  medicine  and  ointment 
have  been  plentifully  prescribed,  yet  no  digital  exami- 
nation has  been  made  ; perhaps  only  a look  has  been 
vouchsafed,  and  the  disease  diagnosed  and  treated  as 
piles,  whereas  fistula,  or  ulceration,  or  even  malignant 
disease  has  been  present. 

Some  forms  of  rectal  disease  are  much  more  common 
than  others,  notably  fistula  and  piles.  The  popular 
mind  seems,  indeed,  to  recognise  the  existence  of  only 
these  two  diseases  of  the  rectum,  for  all  affections  of 
this  part  are  generally  classed  by  the  public  under  one 
or  other  of  these  heads.  The  following  is  a table 
showing  the  relative  proportions  found  in  4000  cases 
taken  from  my  own  practice  at  St  Mark’s  Hospital. 


INTRODUCTORY. 


3 


Analysis  of  4000  consecutive  cases  observed  by  Mr 
Allingham , in  the  out-patients’  department  of  St 
Marie’s  Hospital. 


^Fistula  .....  1208 

Abscess,  196  (of  these  151  became  fistulae,  the  rest 

probably  were  cured)  . . .45 

Haemorrhoids,  internal  . . . 863 

„ external  . . . 102 

Fissure  or  painful  ulcer  . . . 446 

Syphilitic  diseases  of  the  anus  and  rectum  . 348 

Ulceration  (neither  malignant  nor  syphilitic)  . 190 

Constipation  ....  185 

Pruritus  ani  ....  180 

Stricture  of  the  rectum  (with  or  without  ulcera- 
tion) .....  178 

Cancer  of  the  rectum  . . .105 

Procidentia  . . . .53 

Polypus  without  fissure  . . .16 

Haemorrhage  (cause  not  ascertained)  . .15 

Impaction  of  faeces  . . . .14 

Neuralgia  . . . . .12 

Dysentery . . . . .12 

Spasmodic  contraction  of  the  sphincter  (no  fissure)  8 
Proctitis  . . . . .7 

Foreign  bodies  in  the  rectum  . . . 5 

Necrosis  of  bone  (sacrum,  and  tuberosity  of  the 

ischium)  . . . .4 

Rodent  ulcer  . . . .2 

Vicarious  menstruation  from  the  rectum . . 2 


4000 


# Of  these  cases  of  fistula  there  were  172  that  presented  more  or  less 
marked  symptoms  of  affection  of  the  lungs,  viz.  haemoptysis,  frequent 
cough,  or  want  of  resonance  in  some  part  of  the  chest. 


4 


INTRODUCTORY 


Some  of  my  critics  have  thought  the  above  table 
misleading,  and  that  haemorrhoids  are  more  common 
than  fistuke.  I do  not  say  that  this  may  not  be  the 
case  if  we  take  into  consideration  the  middle  and 
upper  classes  as  well  as  the  labouring  population, 
whose  cases  alone  are  included  in  my  table.  Slight 
cases  of  piles  do  not  often  present  themselves  at  the 
hospital,  for  the  labouring  man  or  woman  struggles  on 
under  an  attack  which  would  certainly  bring  the  well- 
to-do  to  the  surgeon.  In  my  private  practice  I find 
during  the  last  seven  years  I have  treated  a few  more 
cases  of  haemorrhoids  than  of  fistula,  but  it  must  be 
observed  that  a large  number  of  the  former  were  of  a 
very  slight  nature,  or  suffering  only  from  external 
piles,  and  not  requiring  any,  or  more  than  trivial, 
operative  interference  for  their  cure. 


CHAPTER  II 

EXAMINATION  OF  PATIENTS 

There  are  certain  questions  wliicli  it  is  desirable  to 
ask  the  patient  when  investigating  a case  of  rectal 
disease,  in  order  that  nothing  may  be  forgotten  or 
overlooked. 

It  should  be  remembered  that  we  have  not  done 
enough  when  we  have  discovered  that  a patient  has 
a certain  malady ; it  is  our  duty  then  to  find  out  if 
any  other  disease  coexists.  Thus,  I often  see  a correct 
diagnosis  made,  as  far  as  regards  piles,  but  at  the 
same  time,  a fissure,  or  fistula,  or  ulceration,  or  even 
malignant  disease  of  the  bowel  has  escaped  observa- 
tion. 

The  following  are  the  principal  queries  I generally 
put : — Is  there  any  pain  ? If  so,  of  what  character  P 
Let  the  patient  describe  it — leading  questions  should 
be  avoided.  Does  the  pain  exist  always,  or  is  it 
intermittent  or  paroxysmal?  Is  the  pain  set  up  or 
increased  by  defsecation  ? Does  it  come  on  as  the 
bowels  are  acting*  or  does  it  follow  immediately  or 
some  time  after  the  action  ? How  long  does  the  pain 
last  ? does  it  pass  away  entirely,  only  to  recur  on  again 
going  to  stool  ? Does  anything  protrude  on  the  bowels 
acting,  or  on  making  exertion  ? If  so,  does  it  bleed  ? 


6 


EXAMINATION  OF  PATIENTS 


Does  it  go  back  spontaneously,  or  has  the  patient  to 
return  it  ? 

Is  there  any  discharge  ? if  so,  what  is  its  nature  ? is 
it  of  offensive  odour  ? Is  the  patient  constipated,  or 
does  he  suffer  from  diarrhoea  ? What  is  the  character 
of  the  faecal  evacuation,  as  to  size,  form,  &c. 

Has  the  patient  incontinence  of  wind  or  faeces  ? Is 
there  any  hereditary  tendency  to  rectal  disease  ? Does 
the  patient  cough,  or  is  there  any  proclivity  to  chest 
affections  ? Ascertain  the  state  of  the  liver ; and 
should  an  operation  be  in  view  never  fail  to  examine 
the  urine  ; any  advanced  disease  of  the  kidneys  will 
in  all  probability  render  an  operation  inadmissible.  In 
the  present  day  much  is  ascribed  to  gout,  and  it  is  well 
to  bear  in  mind  that  a gouty  person  suddenly  confined 
to  bed  is  liable  to  get  an  attack  which  may,  at  all  events 
unpleasantly,  complicate  the  case ; lastly,  inquire  into 
habits,  especially  with  reference  to  the  consumption  of 
alcoholic  drinks.  I am  by  no  means  one  of  those  who 
think  a moderate  indulgence  in  beer  or  light  wine 
damaging  to  the  hard- worked  man,  but  a patient  satu- 
rated with  alcohol  is  the  worst  subject  a surgeon  can 
have  to  deal  with.  In  such  a case  I always  insist  on 
four  weeks’  total  abstinence,  and  at  the  same  time  that 
the  patient  should  be  subjected  to  preparatory  treatment 
before  anything  in  the  way  of  operation  is  attempted. 

In  women,  inquire  into  the  condition  of  the  uterus, 
and  if  any  suspicion  is  aroused  make  such  investigation 
as  will  satisfy  yourself  as  to  its  state. 

When  your  verbal  interrogations  are  concluded,  make 
your  examination.  There  are  various  postures  and 
methods  in  which  this  examination  can  be  conducted. 
Some  surgeons  prefer  the  patient  to  kneel  on  a chair 


EXAMINATION  OE  PATIENTS 


7 


and  lean  over  tbe  back,  others  to  kneel  on  a sofa,  the 
head  being  lower  than  the  buttocks,  others  the  litho- 
tomy position,  but  on  the  whole,  I think,  the  most 
comfortable  and  delicate  position  for  the  patient,  and 
that  most  generally  convenient  for  the  surgeon,  is  to 
lie  on  the  right  side  on  a couch,  with  the  knees  drawn 
up  to  the  abdomen.  In  special  examinations  to  dis- 
cover growths  or  strictures,  I often  direct  the  patient 
to  stand  up  and  bear  down ; in  this  manner  the  diseased 
parts  will  be  brought  nearer  to  the  anus,  and  so  enable 
you  to  reach  nearly  a couple  of  inches  higher  than  you 
can  when  the  patient  is  lying  down  in  the  usual  position, 
even  if  he  strain  down. 

To  commence.  Externally,  what  is  to  be  seen  ? 
Note  any  discoloration,  the  condition  of  the  anus, 
patulous,  contracted  or  nipple-shaped.  Look  for 
tumours,  ulceration,  or  fistulous  orifices;  feel  around 
outside  the  anus  with  the  forefinger  for  induration  in 
any  part ; by  this  means  the  situation  of  an  abscess  or 
sinus  may  be  discovered,  and  the  condition  of  the 
sphincter  as  to  spasm  observed.  Then,  if  possible, 
administer  an  injection  of  warm  water.  I hold  that  no 
examination  of  the  bowel  can  be  considered  complete 
if  this  be  dispensed  with.  After  the  contents  of  the 
bowel  are  voided,  you  see  what  protrusion  has  taken 
place,  if  any ; remark  its  character  in  every  way,  par- 
ticularly as  to  structure,  vascularity,  mode  of  origin 
from  the  bowel,  by  peduncle  or  otherwise;  finally, 
examine  the  interior  of  the  bowel  with  the  finder. 
Never  neglect  this.  Much  information — to  the  initiated 
generally  all  that  is  needed — is  to  be  obtained  by  pass- 
ing the  instructed  and  practised  finger  into  the  rectum  ; 
internal  fistulous  orifices,  polypi,  minute  ulcerations, 


8 


EXAMINATION  OF  PATIENTS 


fissures,  &c.,  can  all  be  easily  detected.  Although 
personally  I do  not  use  a speculum  very  frequently,  in 
some  cases  it  is  a valuable  aid  to  diagnosis.  I have 
had  many  varieties  of  that  instrument  constructed,  to 
be  used  with  or  without  artificial  light ; but  for  ordi- 
nary use  the  plated  metal  speculum  employed  at  St 
Mark’s  Hospital  is,  in  my  opinion,  the  best.  It  is  open 
up  one  side  and  at  both  ends,  and  has  a well-fitting 
wooden  plug ; the  whole  is  so  shaped  as  to  resemble 
as  much  as  possible  a forefinger.  It  is  made  by  most 
instrument  makers — Ferguson,  Weiss,  Krohne,  and 
others.  Some  surgeons  prefer  the  bi- valve  speculum 
and  I like  it  also,  its  only  drawbacks  are  some  difficulty 
of  introduction,  and  the  risk  of  injuring  the  mucous 
membrane  during  withdrawal. 

When  you  desire  to  explore  the  rectum  high  up  you 
may,  with  advantage,  use  a long  metal  tube  with  the 
interior  “ nickelled,”  one  end  being  trumpet-shaped 
and  large.  The  smaller  end  may  be  about  three 
quarters  of  an  inch  in  diameter,  and  it  is  very  easily 
introduced  into  the  bowel  by  using  as  the  plug  a small 
india-rubber  bag,  which  you  can  inflate  with  air  by 
means  of  a syringe.  Useful  as  the  above  is,  to  make 
a thorough  examination  of  the  rectum  for  the  purpose 
of  diagnosing  the  existence  of  ulcerations,  malignant 
or  other  growths,  too  high  up  the  bowel  to  reach  with 
the  finger,  it  is  best  to  place  the  patient  under  the 
influence  of  an  anaesthetic,  and  in  the  prone  position, 
with  the  hips  well  elevated  upon  hard  pillows  so  that 
the  intestines  will  gravitate  towards  the  diaphragm, 
and  then  gradually  and  gently  by  palpation  to  dilate 
the  sphincters,  taking  four  or  five  minutes  in  accom- 
plishing this  operation.  When  thoroughly  done  the 


To  face  p.  8 


Fig.  1. 

Mr.  Allingham’s  Four-bladed  Speculum. 


Fig.  2. 

Speculum  Ani. 


EXAMINATION  OE  PATIENTS 


9 


whole  rectum  is  opened  to  view,  and,  if  one  or  two 
retractors  are  also  used,  nothing  can  escape  careful 
observation.  I need  scarcely  say  before  any  thorough 
examination  is  made,  the  bowel  must  be  well  cleared 
out  by  aperients  and  injections,  and  also  you  must  be 
provided  with  sponges  mounted  on  holders  to  wipe 
away  all  discharge  that  would  impede  your  view. 

Even  when  this  has  been  done  something  more  may 
be  desirable,  and  that  is  the  introduction  of  the  hand 
and  arm  into  the  intestine.  In  the  year  1867,  I first 
introduced  my  hand  and  arm  into  the  bowel  of  a woman 
at  St  Mark’s  Hospital,  and  found  a malignant  stric- 
ture in  the  sigmoid  flexure.  From  that  time  I have  on 
many  occasions  repeated  this  manoeuvre,  and  have 
saved  several  lives.  In  one  case  which  I saw  with  Dr 
Wilson  Fox  and  Mr  Towne,  of  Kingsland,  I found  and 
completely  stretched  a band  of  false  membrane  or  peri- 
toneum which  was  binding  down  the  bowel  as  it  crossed 
the  brim  of  the  pelvis ; the  obstruction  was  relieved 
and  the  patient  recovered. 

Up  to  the  year  1878  I had  never  introduced  my 
hand  into  the  male  rectum,  believing  that  it  was  impos- 
sible that  a man's  hand  could  be  passed  through  the 
comparatively  unyielding,  narrow  inlet  to  the  male 
pelvis ; but  learning  that  the  late  Professor  Simon,  of 
Heidelberg,  had  accomplished  this,  I have  on  many 
occasions  (my  hand  being  small)  followed  his  example 
without  inflicting  any  injury.  I do  not,  however,  think 
that,  at  all  events  in  a man,  much  aid  to  diagnosis  is 
gained,  the  hand  being  so  firmly  compressed  in  the 
sigmoid  flexure  as  to  prevent  extensive  manipulation. 

I need  scarcely  say  in  this  proceeding  the  utmost 
gentleness  should  be  used,  and  that  a small  hand  is 


10 


EXAMINATION  OF  PATIENTS 


absolutely  necessary.  Dr  Heslop,  of  Birmingham, 
relates  in  the  ‘Lancet,’  May  11th,  1872,  two  cases  of 
death  in  women  after  passing  the  hand  into  the  rectum, 
and,  I think,  justly  infers  that  the  operation  was  the 
cause  of  rupture  of  the  bowel  close  to  or  above  the 
stricture.  I have  myself  seen  death  result  from  this 
procedure  in  a case  where  I believe  no  undue  violence 
was  employed.  My  opinion  is  that  in  this  operation 
where  a stricture  exists  it  should  not  be  forcibly  or 
widely  dilated,  and  that  the  dilatation  should  not  be 
followed  by  copious  enemata,  which  will  unduly  distend 
the  weak  part  of  the  intestine  and  cause  much  strain- 
ing ; it  is  better  not  even  to  give  any  purgative  for  at 
least  forty* eight  hours,  and  I think  it  wise  to  adminis- 
ter repeatedly  small  doses  of  opium. 

Referring  again  to  the  condition  of  the  rectum  after 
well  dilating  the  sphincters,  I wish  to  point  out  how 
easily  operations  may  be  performed — >a  large  bi- valve 
vaginal  speculum  may  be  introduced,  or  Bozeman’s 
duck-bill,  and  recto-vesical  openings  may  be  readily 
closed.  I have  now  on  three  occasions  successfully 
sewn  up  large  vesico-rectal  fistulas  made  by  experienced 
surgeons  in  performing  lithotomy.  I have  removed  a 
piece  of  stick  three  and  a half  inches  in  length,  which 
a man  had  introduced  into  his  rectum  and  allowed  to  es- 
cape into  the  bowel,  where  it  got  fixed  cross-wise  in  the 
rectum  so  high  up  as  not  to  be  felt  by  the  finger,  and 
also  an  impaction  of  feces  measuring  three  inches  in 
diameter,  the  nucleus  of  which  was  a large  biliary  cal- 
culus. As  regards  impactions  generally,  after  dilata- 
tion of  the  sphincters,  the  whole  mass  can  be  removed 
at  one  sitting,  and  this  is  a great  advantage.  I shall 
have  occasion  further  on  to  again  consider  this  ques- 


EXAMINATION  OF  PATIENTS 


11 


tion  of  so-called  fC  forcible  dilatation.’ 5 In  examining 
the  rectum  in  women,  Dr  Horatio  Storer,  of  Boston, 
TJ-S.,  has  recommended  eversion  by  the  fingers  passed 
into  the  vagina.  This  method  is  useful  in  women  who 
have  borne  children,  but  not  in  the  young  and  unmar- 
ried. Moreover,  it  is  only  the  anterior  wall  of  the 
rectum,  and  that  not  high  up,  that  this  method  enables 
you  to  examine ; by  putting  your  fingers  into  the 
vagina  you  cannot  bring  down  the  posterior  wall  of 
the  rectum,  as  I have  assured  myself  on  many  occa- 
sions. 


CHAPTER  III 


FISTULA  IN  ANO 

Fistula  is,  at  all  events  in  hospital  practice,  the 
most  common  rectal  disease  affecting  the  adult.  Out 
of  4000  cases,  taken  consecutively  and  without  selec- 
tion at  St.  Mark’s  Hospital  from  the  out-patient 
department,  there  were  1057  persons  suffering  from 
fistula,  and  196  from  abscess,  of  which  151  subse- 
quently became  fistulse,  so  that  more  than  one-fourth 
of  the  whole  cases  treated  were  fistula.  I have  recently 
examined  the  records  of  the  in-patients  at  St.  Mark’s 
Hospital  during  several  years,  and  these  show  that 
two-thirds  of  those  operated  upon  were  cases  of  fistula. 
There  is  one  great  difficulty  in  making  deductions  from 
statistics  which  deserves  mention  ; it  is  due  to  the  fact 
that  many  patients  suffer  from  more  than  one  malady. 
It  constantly  happens  that  a fistula  is  found  in  con- 
nection with  hsemorrhoids  either  as  the  substantive 
disease  or  as  a complication.  Again,  a fissure  or 
circular  ulcer  often  has  a sinus  running  from  it,  so 
that  it  may  fairly  be  considered  as  the  opening  of  an 
internal  fistula,  and  the  case  called  a fistula,  or  the 
sinus  is  not  detected  and  the  case  is  called  ulcer  or 
fissure,  and  so  error  creeps  in. 

Men  are  more  subject  to  fistula  than  women. 


51 

1423 


FISTULA  IN  ANO 


13 


Tliis  disease  is  most  frequently  met  with  during 
middle  age,  but  it  is  by  no  means  restricted  to  that 
period  of  life.  I have  operated  upon  an  infant  in  arms 
and  upon  a man  seventy-eight  years  of  age. 

The  causes  of  fistula,  or  abscess  ending  in  fistula, 
are  many  and  various,  and  several  causes  may  combine 
to  produce  the  result. 

These  may  be  generally  specified : — Injury  to  the 
anus,  injury  to  the  mucous  membrane  of  the  bowel 
by  very  costive  motions,  by  straining  at  stool,  by 
foreign  bodies  swallowed  (fishbones,  and  the  bones  of 
rabbits  are  occasionally  found  in  rectal  abscesses), 
exposure  to  wet  and  cold,  and  particularly  sitting 
upon  damp  seats  after  exercise,  when  the  parts  are  hot 
and  perspiring ; — I have  traced  many  cases  of  rectal 
abscess  to  sitting  on  the  outside  of  an  omnibus  shortly 
after  active  exertion — the  scrofulous  diathesis;  and 
certain  depraved  conditions  of  the  blood,  such  as  fre- 
quently give  rise  to  boils  or  carbuncles.  Here  I would 
observe  that  sudden  and  deep-seated  suppuration  is 
often  found  to  occur  after  severe  itching  in  the  part 
with  only  erythematous  redness  on  the  surface. 

Fistula  in  children  almost  always  results  from  worms 
or  injury  to  the  anal  region. 

Fistula,  in  the  majority  of  cases,  commences  by  the 
formation  of  an  abscess  immediately  beneath  the  skin 
just  outside  the  anus ; it  is  generally  said  to  commence 
in  the  ischio-rectal  fossa,  but  I am  certain  this  is  the 
rarer  situation ; it  may  also  begin  by  ulceration  of  the 
mucous  membrane  of  the  rectum,  as  seen  in  phthisical 
patients ; when  it  arises  in  this  manner  faecal  matter 
collects  in  the  connective  tissue,  and  then  an  abscess 
will  form  and  open  outside ; and,  lastly,  an  abscess 


14 


FISTULA  IN  ANO 


may  form  in  the  sub-mucous  connective  tissue  cf  the 
rectum,  and  then  burst  into  the  bowel.  This  is  its 
ordinary  termination,  but  it  may  insidiously  under- 
mine the  rectum  in  any  direction,  and  lam  convinced 
that  the  most  serious  forms  of  fistula  not  uncommonly 
originate  in  this  manner. 

Rectal  abscess  may  arise  rapidly,  when  there  will  be 
redness,  tenderness  and  often  very  acute  pain  with 
constitutional  disturbance ; or  it  may  be  months  in 
formation,  and  be  perfectly  painless  even  on  manipu- 
lation ; the  only  evidence  of  the  abscess  being  a flat, 
boggy,  crepitating  enlargement,  which  can  be  felt  at 
the  side  of  the  anus.  This  form  of  abscess  is  the  most 
dangerous  as  it  is  apt  to  be  neglected ; it  has  little 
tendency  to  open  spontaneously,  and  it  results  in  a 
burrowing  up  by  the  side  of  the  rectum  to  some  dis- 
tance, as  well  as  under  the  skin  towards  the  perineum 
or  buttock,  or  both. 

I think,  on  the  whole,  by  far  the  most  usual  course 
is  for  the  abscess  to  form  rapidly,  with  great  pain,  and 
if  not  interfered  with  to  burst  externally ; the  patient 
then  becomes  suddenly  easy,  and  fancies  that  his 
trouble  is  over.  The  cavity  of  the  abscess  seldom 
entirely  closes,  but  sooner  or  later  it  contracts,  leaving 
a weeping  sinus  with  a pouting,  papillary  aperture, 
which  may  be  situated  near  or  far  from  the  anus. 

It  is  not  often  that  one  sees  a rectal  abscess  very 
early ; either  the  patient  is  not  aware  of  the  import- 
ance of  attending  to  the  early  symptoms,  or  he  tem- 
porises, using  fomentations  or  poultices ; or  even  when 
seen  by  a surgeon,  the  proper  treatment  is  not  always 
promptly  adopted.  I have  seen  large  abscesses  painted 
with  iodine  under  the  idea  of  obtaining  absorption. 


FISTULA  IN  ANO 


15 


It  is  well  to  remember  that  as  soon  as  pus  is  formed, 
there  is  only  one  method  of  treatment  to  be  for  a 
moment  entertained,  and  that  is  incision.  It  is  cer- 
tainly less  damaging  to  cut  into  an  inflamed  swelling 
near  the  anus  without  finding  pus  than  to  let  a day 
pass  over  after  suppuration  has  commenced ; the 
longer  the  abscess  is  left  unopened  the  greater  the 
danger  of  the  formation  of  lateral  sinuses.  Before  any 
pus  exists,  rest,  warm  fomentations  and  leeches  may 
cut  short  the  attack,  but  such  a result  is  very  rare. 
Very  small  abscesses  can  be  well  and  easily  opened  in 
the  following  way  : — Place  the  patient  on  the  side  on 
which  the  swelling  exists ; pass  the  forefinger  of  the 
left  hand,  well  anointed,  into  the  bowel;  then  place 
the  thumb  of  the  same  hand  below  the  swelling  on  the 
skin.  Now  make  outward  pressure  with  your  finger 
in  the  bowel,  and  you  render  the  swelling  quite  tense 
and  defined,  it  being,  in  fact,  taken  between  your  finger 
and  thumb.  A curved  bistoury  is  then  to  be  thrust 
well  into  the  abscess,  in  a direction  parallel  to  the  long 
axis  of  the  bowel,  and  made  to  cut  its  way  out  towards 
the  anus ; it  is  well  to  make  a thoroughly  free  incision, 
commencing  at  the  outermost  part  of  the  swelling.  If 
the  part  be  thoroughly  frozen  by  the  ether-spray,  this 
operation,  otherwise  exquisitely  painful,  may  be  ren- 
dered almost,  if  not  quite,  painless. 

The  method  of  operating  above  described  is  by  no 
means  suitable  to  a severe  or  deep-seated  abscess  ; I 
can,  however,  safely  say  that  if  a patient  suffering  from 
this  latter  form  will  allow  me  to  act  in  my  own  way,  I 
can  almost  guarantee  that  no  fistula  shall  result.  The 
following  is  the  method  to  be  adopted.  The  patient 
must  take  an  anaesthetic,  as  the  operation  is  very 


16 


FISTULA  IN  ANO 


painful.  I first  lay  the  abscess  outside  the  anus,  open 
from  end  to  end,  and  from  behind  forwards,  i.  e.  in  the 
direction  from  the  coccyx  to  the  perineum.  I then 
introduce  my  forefinger  into  the  abscess  and  break 
down  any  secondary  cavities  or  loculi,  carrying  my 
finger  up  the  side  of  the  rectum  as  far  as  the  abscess 
goes,  probably  under  the  sphincter  muscles,  so  that 
only  one  large  sac  remains ; should  there  be  burrowing 
outwards,  I make  an  incision  into  the  buttock  deeply, 
at  right  angles  to  the  first.  I then  syringe  out  the 
cavity  and  carefully  fill  it  with  wool  soaked  in  carbo- 
lised  oil,  one  part  to  ten  or  twelve,  this  I leave  in  for  a 
day  or  two,  then  take  it  out  and  examine  the  cavity, 
and  dress  again  in  the  same  manner,  but  in  addition  I 
now  use,  if  I think  it  necessary,  one  or  more  drainage 
tubes.  In  a remarkably  short  time  these  patients 
recover;  the  sphincters  have  not  been  divided,  and 
the  patient  therefore  escapes  the  risk  of  incontinence  of 
faeces  or  flatus  which  sometimes  occurs  when  both  the 
sphincters  are  deeply  incised.  I could  cite  numbers  of 
cases  of  very  unfavorable  aspect,  and  in  old  persons, 
that  have  done  quite  well,  treated  as  I have  described. 

To  give  your  patient  the  best  possible  chance  of 
recovery,  you  must  keep  him  on  the  sofa,  if  not  in  bed. 
I always  think  it  advisable  to  clear  out  the  bowels 
once,  and  then  confine  them  by  an  astringent  dose  of 
opium  for  three  days ; you  thus  secure  entire  rest  to 
the  parts,  and  give  every  opportunity  for  the  cavity  of 
the  abscess  to  fill  up.  After  a time  the  carbolised  oil 
should  be  discarded  and  lotions  used  containing  nitrate 
of  silver,  copper,  zinc,  or  friar’s  balsam,  which  last 
does  great  good.  I find  boracic  acid  ointment,  not 
strong,  or  a solution  of  thymol  advantageous;  you 


FISTULA  IN  ANO 


17 


must  be  prepared  to  ring  the  changes ; but  one  thing 
always  remember,  never  stuff  an  abscess,  but  put  wool 
in  very  lightly  and  use  drainage  tubes  ; on  the  whole 
I prefer  the  india-rubber  tube  to  any  other  contrivance, 
and  have  had  the  best  results  from  it,  as  it  gives  rise 
to  no  pain,  an  advantage  which  cannot  be  claimed  for 
either  the  wire  tube  or  the  horsehair. 

The  questions  naturally  arise,  Why  do  these  abs- 
cesses usually  fail  to  close  up  ? Why  do  they  form 
sinuses  ? There  are  doubtless  several  reasons,  but 
the  following  may  be  sufficient.  The  mobility  of  the 
parts,  caused  by  action  of  the  bowels  and  movement  of 
the  sphincter  muscles,  almost  at  every  breath,  and  the 
presence  of  much  loose  areolar  tissue  and  fat.  The 
vessels  also  near  the  rectum  are  not  well  supported, 
and  the  veins  have  no  valves  ; there  is  therefore  ten- 
dency to  stasis,  and  this  is  inimical  to  rapid  granula- 
tion. We  know  that  abscesses  are  always  apt  to  de- 
generate into  sinuses  when  situated  in  any  lax  areolar 
tissue,  as  in  the  axilla,  neck,  or  groin. 

After  an  abscess  has  long  existed  the  discharge 
loses  its  purulent  character  ; it  becomes  watery ; the 
abscess  has  gradually  contracted,  and  now  only  a 
sinus,  very  often  formed  of  dense  tissue,  remains.  If 
this  sinus  be  laid  open,  you  may  observe  that  its 
interior  resembles  in  appearance  the  inner  coat  of  an 
artery,  so  glistening  and  smooth  has  it  become.  This 
was  formerly  called  a pyogenic  membrane  ; it  certainly 
secretes  pus,  but  it  is  not  a membrane. 

If  now  a probe  be  passed  very  tenderly  into  this 
sinus,  allowing  it  to  follow  its  own  course,  and  after 
this  is  done,  the  finger  be  placed  in  the  rectum,  you 
will  probably  find  that  the  probe  has  traversed  the 

2 


18 


FISTULA  IN  ANO 


sinus,  passed  through  an  internal  opening,  and  can  be 
felt  in  the  bowel.  In  this  case  you  would  have  a 
typical,  simple,  complete  fistula ; and  this  is  by  far 
the  most  common  variety,  very  few  fistulm  that  have 
existed  for  more  than  three  months  being  without  an 
internal  opening. 

Besides  this  common  form  there  are  two  other 
descriptions  of  fistula,  viz.  the  blind  external  fistula, 
and  the  blind  internal  fistula.  In  the  blind  external 
fistula  there  is  an  external  opening,  and  it  is  therefore 
called  an  external  fistula,  but  no  internal  opening,  hence 
<c  a blind  external .”  In  the  other  variety  there  is  an 
internal  opening,  consequently  it  is  an  internal  fistula, 
and  there  is  no  external  opening,  therefore  it  must  be 
called  a blind  internal  fistula. 

I have  so  often  seen  confusion  in  the  use  of  these 
terms  that  I have  been  particular  in  describing  them ; 
and,  considered  in  the  way  I have  put  it,  I think  there 
can  be  no  misconception. 

The  blind  internal  form  of  fistula  results  usually  from 
some  injury  to,  or  ulceration  of,  the  lining  membrane 
of  the  rectum,  or  abscess  in  the  connective  tissue 
beneath  the  mucous  membrane,  and  is  most  commonly 
found  in  subjects  who  have  consumption  or  who  are 
predisposed  to  it. 

Now,  these  terms,  “ complete,’ * “ blind  external,”  and 
“ blind  internal,”  are  useful,  but  surgically  they  are  of 
little  moment ; there  is  a very  much  more  important 
division  which  affects  the  character  of  the  fistula  as 
regards  its  seriousness  to  the  patient  and  also  to  the 
surgeon,  I mean  the  division  into  anal  fistula  and  pel- 
vic or  rectal  fistula.  An  anal  fistula  is  one  which, 
commencing  on  the  skin  a few  lines  from  the  margin 


FISTULA  IN  ANO 


19 


of  tlie  anus,  opens  just  inside  the  orifice,  passes  at 
most  under  a few  fibres  of  the  external  sphincter,  and 
is  trivial  and  can  be  rapidly  and  safely  cured.  By  pel- 
vic or  rectal  fistula  I mean  a fistula  which,  commencing 
probably  by  an  abscess  in  the  ischio-rectal  fossa,  passes 
underneath  both  the  sphincter  muscles  and  opens  pos- 
sibly high  up  in  the  bowel,  indeed  in  the  pelvis.  This 
is  the  fistula  which  is  dangerous  to  the  patient,  and 
will  call  forth  all  the  knowledge  and  experience  of  the 
surgeon  to  bring  to  a successful  issue.  My  friend  Dr 
David  Molliere,  of  Lyons,  in  his  exceedingly  exhaustive 
and  able  work  on  c Diseases  of  the  Rectum,’  makes 
practically  the  same  division,  calling  the  first  Cf  Fistules 
sous-tegumentaires,”  and  the  second  “ Fistules  sous- 
musculaires.” 

We  will  now  imagine  that  you  have  a fistulous 
patient  before  you.  Proceed  to  examine  him  thus  : — 
Place  him  upon  a hard  couch  on  the  side  upon  which 
the  disease  is  supposed  to  be  situated,  the  buttocks 
being  brought  close  to  the  edge  of  the  couch,  and  the 
knees  drawn  up.  Look  at  the  anus  and  the  surround- 
ing parts  carefully , to  detect  any  visible  malady.  You 
may  see  the  orifice  of  a sinus,  or  some  discoloration  of 
the  skin  may  show  you  the  site  of  the  disease.  Then 
feel  gently  all  round  the  anus  with  the  forefinger,  and 
you  will  often,  by  the  induration,  detect  the  course 
and  position  of  the  sinus,  which  feels  like  a pipe 
beneath  the  skin.  Having  satisfied  yourself  in  these 
respects,  pass  the  probe  into  the  external  aperture ; 
hold  the  probe  with  a very  light  hand,  and  let  it  almost 
find  its  own  way.  In  many  cases,  as  I have  before 
said,  it  will  pass  right  into  the  bowel ; when  the  probe 
has  been  passed  as  far  as  it  will  go  without  using  any 


20 


FISTULA  IN  ANO 


force,  introduce  the  forefinger  of  the  left  or  right 
hand,  whichever,  according  to  the  position  of  the 
patient,  is  most  convenient,  into  the  rectum ; do  not, 
as  is  often  done,  introduce  your  finger  before  the  probe, 
if  you  do,  you  will  excite  contraction  of  the  sphincter, 
and  the  sinus  will  be  drawn  up  or  contorted,  and 
consequently  the  passage  of  the  probe  is  obstructed. 
When  the  finger  is  in  the  bowel,  if  the  probe  has  not 
come  through  the  internal  orifice,  feel  for  the  opening 
— an  educated  digit  will  nearly  always  detect  it ; and 
having  found  the  opening,  you  can  with  the  other 
hand  guide  the  probe  towards  it. 

The  internal  aperture  is  usually  situated  just  within 
the  anus,  in  the  depression  which  exists  between  the 
external  and  internal  sphincters.  I do  not  say  that  it 
is  by  any  means  invariably  so  placed,  but  I am  sure 
that  this  is  its  common  situation  ; and  one  reason  why 
the  opening  is  not  felt  when  the  finger  is  inserted  is 
because  the  search  for  it  is  made  too  high  up  the 
bowel. 

I think  the  reason  the  internal  opening  is  situated 
so  often  in  the  position  I have  named,  is  this.  The 
abscess  forming,  in  most  cases,  just  outside  the  anus, 
does  not  burrow  deeply,  but  passes  close  under  the 
external  sphincter  ; it  then  is  prevented  from  ascending 
higher  up  the  bowel  by  the  thick  band  of  the  internal 
sphincter,  and  consequently  is  turned  inwards,  and 
makes  its  way  through  the  lax  areolar  tissue,  in  the 
space  between  the  two  muscles.  When  the  abscess 
really  commences  in  the  ischio-rectal  fossa,  it  burrows 
deeply,  and  then  most  usually  passes  beneath  the 
internal  sphincter,  and  opens,  if  at  all,  high  up  in  the 
rectum . 


FISTULA  IN  ANO 


21 


Occasionally  more  tlaan  one  internal  opening  exists, 
and  I have  now  many  times  seen  wliat  the  late  Mr 
Syme  declared  could  not  occur,  viz.  two  internal  open- 
ings in  the  same  patient  at  the  same  time ; at  St  Mark’s 
I recently  treated  a case  in  which  there  was  an  internal 
aperture  at  each  side  of  the  bowel. 

It  is  all-important  that  this  internal  aperture  be  felt 
with  the  finger  (so  that  in  operating  it  may  be  included 
in  your  incision),  for  not  unfrequently  from  the  tor- 
tuous nature  of  the  fistula  the  probe  cannot  readily  be 
got  through  it ; this  is  markedly  the  case  in  the  horse- 
shoe form  of  fistula,  which  is  not  uncommon.  The 
sinus  here  runs  round — generally  dorsally — from  one 
side  of  the  anus  to  the  other,  so  that  the  external  and 
internal  openings  are  placed  on  opposite  sides  of  the 
bowel.  This  variety,  if  not  properly  diagnosed,  is 
rarely  cured  by  operation,  the  sinus  being  laid  open 
on  one  side  of  the  bowel,  and  left  untouched  on  the 
other ; this  mistake  may  generally  be  avoided  by  a 
careful  examination  with  the  finger  externally,  as  you 
can  feel  a hardness  on  both  sides  of  the  anus ; the 
patient  will  also  sometimes  assist  you  by  telling  you 
that  he  has  felt  something  like  a cc  piece  of  wire  55  on 
both  sides  of  the  bowel. 

When  you  pass  your  finger  into  the  bowel  to  search 
for  the  internal  opening,  never  forget  to  carry  it 
higher  up  to  see  if  the  rectum  be  otherwise  healthy ; 
you  may  find  stricture,  ulceration,  or  malignant  disease 
co-existent ; without  this  precaution  these  conditions 
may  be  overlooked. 

A fistula  may  be  a very  trivial  matter  indeed,  which 
you  can  operate  upon  in  the  out-patients’  room,  and 
send  your  patient  home  afterwards,  or  it  may  be  a 


22 


FISTULA  IN  ANO 


really  serious  affair,  demanding  extensive  surgical 
interference.  I have  often  seen  a buttock  so  riddled 
with  sinuses  as  to  resemble  a miniature  rabbit-warren 
more  than  anything  else. 

Fistula  may  exist  for  years  without  causing  much 
pain  or  inconvenience  to  the  patient.  I have  met  with 
many  persons  who  have  had  rectal  sinuses  for  ten  years 
and  upwards,  and  never  had  anything  more  done  than 
the  occasional  passing  of  a probe  when  the  external 
aperture  got  blocked  up,  and  pain  was  caused  by  the 
formation  and  retention  of  matter. 

When  the  tissues  around  the  sinus  become  very 
dense  there  may  be,  for  a long  period,  an  arrest  of 
burrowing,  but  an  attack  of  inflammation  set  up  at 
any  time  will  cause  a fresh  abscess. 

When  seeking  to  determine  whether  you  can  safely 
leave  a fistula  for  a time,  the  nature  of  the  case  is  an 
important  element  for  consideration.  The  blind  exter- 
nal fistula  is  the  safest  to  leave.  An  internal  fistula 
with  a large  internal  opening,  and  the  sinus  running 
from  it  towards  the  anus,  is  sure  to  burrow,  because, 
being  funnel-shaped,  with  the  larger  end  of  the  funnel 
upwards,  faeces  readily  pass  into  it,  and  inflammation, 
much  pain,  and  extension  of  the  disease  will  certainly 
ensue. 

Usually  it  may  be  said  the  longer  a fistula  is  left  the 
more  does  it  burrow,  and  the  more  difficult  is  it  of 
cure ; therefore  I think  it  unwise  to  tell  a person  to 
have  nothing  done  as  long  as  he  is  not  suffering — advice 
which  I frequently  hear  is  given  to  patients. 

I am  often  anxiously  asked  by  sufferers  if  a fistula 
can  be  cured  without  an  operation,  or,  as  they  say, 
“ the  use  of  the  knife.”  To  this  I reply  that  I have 


FISTULA.  IN  ANO 


23 


seen  all  kinds  of  fistula  get  well  with  and  even  without 
treatment,  but  these  occurrences  are  quite  exceptions 
to  the  rule,  and  should  not  be  depended  upon ; still, 
if  the  fistula  be  simple  and  the  patient  be  unwilling  to 
submit  to  any  operation,  certain  methods  may  fairly  be 
tried.  For  the  last  few  years  I have  been  successful, 
on  many  occasions,  in  curing  blind  external,  and  even 
complete  fistulae,  by  means  of  carbolic  acid  and 
drainage  tubes.  This  mode  of  treatment,  if  carried 
out  with  great  care  and  some  perseverance,  offers,  in 
my  opinion,  the  best  chance  for  the  patient.  I find  it 
is  essential  that  the  outer  opening  of  the  fistula  should 
be  much  dilated  before  applying  the  acid  or  using 
tubes.  The  dilatation  can  be  accomplished  by  keeping 
in  a small  portion  of  sea-tangle  for  a few  days,  or  by 
a small  sponge  tent.  When  the  opening  is  large 
enough  I clean  out  the  sinus  well,  and  then  rapidly 
run  down  to  the  end  of  it  a small  piece  of  wool 
saturated  in  strong  carbolic  acid  with  10  per  cent,  of 
water.  I mount  the  wool  upon  a stiff  piece  of  wire 
set  in  a handle  and  just  roughened  at  the  free  end. 
The  wool  can,  with  a little  practice,  be  wound  tightly 
on  the  end  of  the  wire  so  as  to  be  small  enough  to  go 
right  to  the  bottom  of  the  sinus.  I then  withdraw  the 
wire  and  put  in  a drainage  tube  just  large  enough  to 
fill  the  sinus,  and  keep  it  in ; the  interior  of  the  sinus 
is,  by  the  acid,  induced  to  granulate,  and  if  you  are 
successful  you  will  find  almost  day  by  day,  that  a 
shorter  drainage  tube  will  be  required  until  the  whole 
sinus  is  filled  up.  It  may  be  necessary  to  apply  the 
acid  more  than  once,  and  to  use  other  stimulants,  as 
Friar’s  balsam,  solutions  of  sulphate  of  copper,  or 
nitrate  of  silver,  &c.,  but  never  strong  injections ; care 


24 


FISTULA  IN  ANO 


should  always  be  taken  to  keep  the  external  opening 
well  dilated.  I had  thought  the  heated  galvanic  wire 
passed  to  the  bottom  of  a sinus  would  be  very  effectual, 
but  many  trials  have  convinced  me  that  it  cannot  be 
relied  on,  and  that  it  causes  much  pain. 

I have  now  seen  many  spontaneous  cures  of  simple 
fistula,  and  have  also  seen  an  ordinary  examination 
with  a probe  set  up  exactly  the  quantity  of  inflamma- 
tion required  to  obliterate  the  sinus,  and  a good  many 
of  such  results  I have  had  opportunities  of  watching, 
and  no  return  has  taken  place ; but,  on  the  other 
hand,  the  bulk  of  the  so-called  spontaneous  cures  are 
illusory  and  the  disease  returns  in  time,  and  even  the 
same  may  be  said  of  those  in  which  treatment,  short  of 
division,  has  seemed  effectual.  In  my  opinion,  there  is 
nothing  equal  to  the  division  of  the  fistula  and  getting 
it  to  fill  up  soundly  from  the  bottom. 

I will  relate  a few  cases  of  spontaneous  cure,  and 
also  an  example  or  so  of  cure  by  treatment,  which  have 
recently  occurred  in  my  practice. 

Spontaneous  cure  of  a blind  external  fistula. — Win.  B — , set.  49,  a 
draper’s  assistant,  admitted  into  St.  Mark’s,  August  30th,  1864.  Had 
an  abscess  five  months  ago  by  the  side  of  the  anus,  which  was  opened, 
and  ever  since  there  has  been  a discharge  from  it ; at  times  it  is  very 
sore  and  swells,  then  it  breaks  and  discharges  again,  and  he  is  quite 
comfortable.  On  examination  a blind  external  fistula  was  found,  the 
orifice  being  close  to  the  external  edge  of  the  sphincter ; the  sinus  ran 
up  quite  an  inch,  and  did  not  approach  near  to  the  mucous  membrane. 
I was  quite  sure,  from  a most  careful  examination,  that  no  internal 
aperture  existed. 

No  treatment  was  adopted,  as  I intended  to  take  him  in  when  there 
was  a vacant  bed.  He  only  had  a little  calomel  ointment  ordered,  and 
a pill  to  keep  the  bowels  acting.  In  three  weeks  he  told  me  the  sinus 
had  healed,  and  on  examination  I found  it  to  be  so;  of  course  I 
expected  it  to  break  out  again. 

October  11th. — It  remains  soundly  healed,  and  the  hardness  is  fast 
disappearing. 


FISTULA  IN  ANO 


25 


December  20th. — The  fistula  remains  quite  well ; there  is  no  evidence 
now  of  where  it  was,  no  mark  of  the  original  aperture,  and  no  indura- 
tion. My  opinion  is  that  the  probing  in  this  case  was  just  sufficient  to 
set  up  granulation  and  rapid  closure  of  the  sinus.  It  did  not  return,  I 
am  sure,  as  the  man  would  certainly  have  come  again  to  me,  being  so 
delighted  with  the  result  of  what  he  considered  my  skilful  treatment. 

Blind  external  fistula ; spontaneous  cure. — J.  C — , set.  46,  a porter  at 
the  Tilbury  Station  ; admitted  into  St.  Mark’s,  May,  1867.  Steady  man  ; 
suffers  from  ague.  Six  months  ago  had  a rectal  abscess,  which  burst, 
and  has  continued  to  discharge  more  or  less  up  to  the  present  time. 
A sinus  was  found  running  some  distance  up  by  the  bowel,  rather 
deeply  situated,  and  not  communicating.  I wished  to  take  him  in,  but 
he  said  he  could  not  lay  up  yet.  Ordered  a mild  aperient,  and  some 
zinc  ointment.  In  a fortnight  he  came  again,  and  said  the  fistula  had 
healed.  I examined  him,  and  found  it  closed ; moreover,  it  was  not 
tender. 

June  7th. — Again  examined  ; found  it  still  well;  no  pain ; very  little 
hardness ; no  discharge  from  the  bowel ; and  I explored  the  rectum  to 
see  if  it  could  have  opened  internally,  but  this  was  not  the  case. 

July. — Saw  him  again,  and  he  was  quite  well,  and  he  has  continued 
so.  I believe  he  has  never  had  any  return  of  this  malady. 

Blind  external  fistula ; spontaneous  cure. — Jas.  L — , set.  65,  came  to 
St.  Mark’s,  July  5th,  1864.  The  external  aperture  was  some  distance 
from  the  anus  ; the  sinus  passed  up  beyond  the  external  sphincter,  and 
the  probe  could  be  felt  rather  nearer  the  mucous  membrane.  No 
particular  treatment.  The  probe  was  passed  again  in  about  a fortnight 
after  he  was  first  seen.  The  sinus  healed  up  while  he  was  waiting  his 
turn  to  come  in.  I kept  him  under  observation  until  the  end  of 
December,  when,  finding  no  return  of  the  fistula,  no  pain,  no  discharge, 
no  internal  opening,  no  hardness  in  the  old  track  of  the  sinus,  I dis- 
charged him  as  cured. 

Complete  fistula  in  ano ; spontaneous  cure. — W.  H.  K — , set.  30,  clerk, 
admitted  into  St.  Mark’s,  April  2nd,  1867.  Not  very  strong ; habits 
regular.  On  examination  a small  but  complete  fistula  was  found  on 
the  right  side  of  the  anus,  the  external  opening  being  quite  an  inch 
from  it,  the  internal  aperture  in  the  usual  place  between  the  two 
sphincters.  In  the  middle  of  May  I took  him  in  as  an  in-door  patient, 
and  on  going  to  operate  I found  the  external  orifice  so  firmly  closed 
that  I could  not  without  unwarrantable  force  get  a probe  into  it ; I 
could  feel  the  internal  aperture  very  small.  There  was  no  pain,  so  I 
left  him.  Next  week  I again  examined  him,  and  found  the  internal 


26 


FISTULA  IN  ANO 


orifice  also  closed.  I kept  him  in  the  hospital  another  week,  and  still 
the  fistula  remained  healed,  so  I put  him  upon  the  out-patient  list,  and 
he  attended  up  to  the  end  of  August,  when,  finding  the  fistula  still 
closed,  and  there  being  no  pain  and  no  induration,  I discharged  him  as 
cured,  requesting  him  to  come  again  immediately  on  any  return  of  pain 
or  swelling.  I have  not  seen  him  since. 

Most  of  the  cases  of  fistula  which  I have  tried  to  cure 
without  an  operation  have  occurred  in  private  prac- 
tice ; the  reason  is,  that  time  is  generally  a great  con- 
sideration to  the  poor  man ; he  does  not  mind  a little 
pain  ; he  wants  to  be  cured  as  quickly  as  possible,  and 
therefore  prefers  to  be  operated  upon  at  once,  in  order 
to  get  well  certainly  and  speedily.  It  is  only  the  rich 
who  can  afford  the  luxury  of  three  or  four  months’ 
treatment,  finding  themselves  perhaps  at  the  end  of  that 
time  in  much  the  same  condition  as  they  were  at  its 
commencement.  Altogether  I find  that  I have  had 
twenty* one  successful  cases,  and  a considerable  num- 
ber in  which  I have  failed  to  effect  a cure  after  a pro- 
longed attempt,  therefore  I cannot  say  the  prospect  is 
very  encouraging,  but  patients  who  will  not  submit  to 
the  knife  will  often  allow  me  to  use  the  elastic 
ligature,  and  of  that  I shall  have  more  to  say  pre- 
sently. 


Cases  cured  by  treatment. 

A gentleman,  set.  50,  a free  liver  and  very  nervous,  came  to  me  with  a 
blind  external  fistula  on  the  right  side,  January  9th,  1875.  I could 
hardly  examine  him  in  consequence  of  his  terror,  so  I ordered  him 
some  sedative  ointment,  and  requested  him  to  come  again  in  three  days. 
He  was  on  his  second  visit  less  timorous,  and  I made  out  that  he  had 
an  anal  fistula  of  the  blind  external  kind.  I advised  division,  first  by 
knife,  then  by  the  elastic  ligature,  but  he  turned  a deaf  ear  to  all  I 
could  say.  Cut  or  tied  he  would  not  be.  The  experience  of  Louis  XIY 
was  nothing  to  him,  and  he  thought  very  disparagingly  of  an  art  which 
could  do  no  better  than  cut  people.  He  readily  assented  to  my  making 


FISTULA  IN  ANO 


27 


trial  of  any  treatment  not  very  painful,  so  I dilated  the  opening  with 
sponge  tent,  and  then  wiped  the  sinus  thoroughly  with  the  carbolic 
acid.  The  pain  was  trivial,  only  slight  burning  for  a few  minutes. 
After  twenty-four  hours  I put  in  a small  india-rubber  drainage  tube. 
He  went  about  as  usual,  but  the  bowels  I kept  confined  for  six  days. 
At  the  end  of  that  time  a copious  enema  of  oil  and  gruel  thoroughly 
relieved  him.  The  discharge  from  the  fistula  had  been  gradually  dimi- 
nishing, and  the  sinus  was  much  less  deep.  All  I now  did  was  to  keep 
the  external  opening  wide  by  a piece  of  sponge,  and  in  three  months  the 
sinus  was  quite  healed.  I have  good  reason  to  know  that  this  case  was 
a genuine  success. 

A gentleman,  set.  40,  robust,  but  wonderfully  cowardly,  came  to  me 
on  the  26th  of  June,  1875.  An  examination  showed  a small  blind 
external  fistula.  He  had  suffered  from  abscess  near  the  rectum,  which 
a gentleman  opened  for  him  nine  months  ago,  and  the  pain  he  had 
gone  through  from  that  was  such  as  to  make  him  determine  that 
nothing  should  persuade  him  to  be  cut  again.  I immediately  proposed 
the  elastic  ligature,  in  which  I assured  him  I had  great  confidence ; but 
unfortunately  he  had,  before  seeing  me,  consulted  a surgeon,  who  related 
to  him  an  awful  case  he  had  experienced  with  the  ligature,  which  did 
not  come  away  for  nine  days,  during  which  time  the  patient  was  in 
incessant  pain.  So  he  would  have  none  of  it.  I dilated  the  external 
opening  with  the  tangle,  and  then  put  in  a drainage  tube,  but  did  not 
use  carbolic  acid  or  any  strong  application,  as  the  patient  feared  pain. 
For  some  time  this  case  did  not  do  well,  and  I was  on  the  point  of 
giving  it  up,  when  I persuaded  him  to  take  an  anaesthetic  and  allow  me 
to  dilate  his  sphincter  muscles  (which  were  very  spasmodically  con- 
tracted), and  apply  the  carbolic  acid.  He  consented;  and  the  result  of 
this  combined  attack,  and  keeping  him  in  bed  a week  conquered  the 
sinus,  and  it  healed  quickly.  I fancy  this  patient  has  remained  well. 

A difficulty  in  these  cases  is  to  keep  the  external 
orifice  very  large  without  irritating  too  much ; and  my 
friend  Mr  Clover,  with  his  usual  ingenuity,  effected 
that  object  wonderfully  well  in  a case  I saw  with  him, 
by  inserting  a bone  collar  stud  into  the  opening. 
When  this  was  slipped  in,  it  remained  fixed,  and  the 
patient  wore  it  and  went  about  without  complaining 
even  of  discomfort ; since  seeing  this  case  I have  tried 
the  collar  stud  on  many  occasions,  but  have  had  a small 
hole  drilled  through  from  end  to  end,  in  order  that  no 


28 


FISTULA  IN  ANO 


pus  might  be  returned  in  the  sinus,  and  it  has  answered 
the  purpose  I desired,  yiz.  to  keep  the  external  orifice 
large. 

A lady  came  to  me  from  the  country  in  the  beginning  of  1879 
with  a small  abscess,  which  had  been  opened,  and  a sinus  running  up  the 
bowel  for  quite  an  inch.  She  was  most  desirous  to  be  cured,  but  would 
not  have  the  knife,  and  feared  the  elastic  ligature.  I was  able,  after  a 
little  dilatation  of  the  orifice,  to  get  the  bone  stud  in,  and  in  ten  days 
the  sinus  had  healed.  To  give  her  every  chance  she  kept  her  sofa,  and 
I confined  the  bowels  for  seven  days.  I saw  this  patient  recently,  and 
she  kept  quite  well. 

Since  the  publication  of  my  last  edition  I have  cured 
many  patients  by  dilatation  of  the  sphincters  and  the 
use  of  the  bone  stud  and  carbolic  acid.  I do  not  think 
anything  would  be  gained  by  relating  more  cases.  One 
practical  point  I would  mention.  The  further  the  ex- 
ternal aperture  is  from  the  sphincter  the  more  likeli- 
hood is  there  that  the  sinus  may  heal.  This  is  shown 
as  well  in  the  cases  of  spontaneous  cure  as  in  my 
own  successes.  It  is  very  important  in  these  attempts 
not  to  do  any  harm.  You  must  always  enjoin  rest 
after  a strong  application,  and  watch  that  not  too 
much  inflammation  be  set  up. 


CHAPTER  IY 

FISTULA  AND  THE  TREATMENT  BY  ELASTIC  LIGATURE 

As  I have  been  considering  the  treatment  of  fistula 
without  cutting,  I think  before  describing  the  usual 
methods  of  operating,  I had  better  relate  my  experi- 
ence of  the  use  of  the  elastic  ligature,  describe  its 
mode  of  application,  and  endeavour  to  point  out  what 
really  it  can  do  and  what  it  cannot  be  expected  to  do. 
And  at  once  I will  fully  confess  that  when  I read  a 
paper  before  the  Medical  Society  of  London,  in 
February,  1875,  on  the  treatment  of  fistula  and  other 
sinuses  by  the  elastic  ligature,  I anticipated  a wider 
use  for  it  than  I have  found.  Still,  I must  assert 
that  the  ligature  is  most  valuable  in  many  cases  and 
frequently  invaluable  as  an  auxiliary  to  the  knife. 

Professor  Dittel,  of  Vienna,  may  certainly  be  called 
the  apostle  of  the  elastic  ligature,  but  he  was  not  the 
discoverer,  as  Mr  Henry  Lee  and  also  Mr  Holthouse 
had  previously  used  it  for  the  removal  of  nsevi  and 
in  anal  fistulse.  When  I read  Professor  Hittel’s  paper 
I came  to  the  conclusion  bhat  the  india-rubber  ligature 
might  be  found  very  useful  in  the  branch  of  surgery 
to  which  I had  paid  special  attention.  I therefore 
determined  to  make  a fair  trial  of  it,  and  have  now 
employed  it  in  more  than  150  varied  cases.  I can 


30 


TREATMENT  BY  ELASTIC  LIGATURE 


truly  say  I have  over  and  over  again  been  very  glad 
that  the  utility  of  the  elastic  ligature  had  been  brought 
forward  by  Professor  Dittel  after  it  had  quite  fallen 
into  oblivion. 

Ligatures  of  thread  have  been  employed  for  a great 
many  years,  even,  we  may  say,  from  the  time  of 
Ambrose  Pare,  for  cutting  through  certain  structures, 
mainly  arteries  ; but  haemorrhoids,  nsevi,  warty  and 
pedunculated  growths  have  constantly  been  removed 
by  the  application  of  a ligature,  and  the  reason  it  has 
not  been  more  extensively  available  has  arisen  from 
the  fact  that  only  a comparatively  limited  thickness  of 
tissue  can  be  cut  through  by  one  application  of  the 
ligature,  which,  as  suppuration  takes  place,  becomes 
loose,  and  then  does  not  penetrate  further  unless  it  be 
re-tightened ; it  is  therefore  only  small  and  soft 
growths  that  can  be  safely  and  advantageously  treated 
by  the  inelastic  thread  ligature. 

Various  means  have  been  devised  to  overcome  this 
inherent  defect,  and  make  the  thread  ligature  cut,  by 
constantly  or  frequently  tightening  the  thread — such 
means  are  shown  in  Picord’s  instrument  for  the  treat- 
ment of  varicocele ; Mr  Luke’s  double  screw,  which 
he  invented  for  cutting  through  rectal  fistulse  which 
ran  so  high  up  the  bowel  as  to  be  considered  dangerous 
of  division  with  the  knife.  A variety  of  methods,  of 
which  a spiral  spring  is  the  essential,  have  also  been 
employed,  from  a wooden  spiral-spring  letter-clip 
up  to  the  very  ingenious  sarcotome  of  Dr  Ainslie 
Hollis. 

To  all  these  methods,  comparatively  good  as  they 
may  be,  some  very  strong  objections  may  be  raised. 
Prom  considerable  experience,  I know  that  Mr  Luke’s 


TREATMENT  BY  ELASTIC  LTGATURE 


31 


double  screw,  advantageous  as  it  has  proved,  causes 
very  intense  pain ; the  daily  or  frequent  necessity  for 
tightening  the  ligature  inflicts  upon  the  patient  a 
torture  often  unendurable,  and  on  many  occasions  the 
knife  has  had  to  complete  what  the  ligature  began,  the 
patient  being  unable  to  endure  the  long-continued 
suffering.  Another  very  grave  objection  to  the  inter- 
mitting application  of  pressure  is  the  frequency  with 
which  secondary  abscesses  result.  I have  noticed  this 
result  in  my  own  practice,  and  seen  it  also  in  that  of 
other  surgeons. 

Dr  Hollis’s  sarcotome  is  very  superior  to  the  others 
in  action,  but  even  this  requires  tightening  or  re-set- 
ting  from  time  to  time;  it  acts  likewise  only  in  one 
direction,  and  therefore  lacks  the  even  circular  pres- 
sure exerted  by  the  india-rubber.  Another  important 
objection  is  its  size  and  weight,  which  render  it  under 
many  conditions  inapplicable. 

It  must  be  evident,  on  reflection,  that  the  pressure 
of  the  india-rubber  band  or  loop  is  not  always  the 
same  during  all  the  progress  of  the  cutting — in  fact, 
it  diminishes  gradually  as  the  loop  of  the  ligature 
becomes  less  in  circumference ; but  practically  the 
pressure  up  to  the  moment  of  separation,  if  the  loop 
be  properly  adjusted  at  first,  is  sufficient  for  its  work. 

The  greatest  pressure  exerted  by  a solid  india- 
rubber  ligature  of  the  thickness  of  l-10th  of  an  inch, 
stretched  to  the  utmost,  only  equals  2J  lbs.  weight ; 
for  example,  6 inches  of  india-rubber,  when  stretched 
to  its  utmost,  i.  e.  3 feet,  exercises  a power  of  lbs. ; 
when  stretched  to  2 feet,  only  a little  more  than  ljlbs.; 
and  when  stretched  only  1 foot,  or  double  its  length, 
^ lb. ; and  even  this  power  is  quite  sufficient,  as  shown 


32 


TREATMENT  BY  ELASTIC  LIGATURE 


by  experiment,  to  pass  through  any  ordinary  tissue,  in 
consequence  of  its  unremitting  and  even  pressure  in 
every  direction. 

I have  for  a long  time  now  used  only  solid  india- 
rubber,  so  strong  that  I cannot  break  it ; and  I put  it 
on  as  tightly  as  I can  and  fasten  it  by  means  of  a 
small  pewter  clip  pressed  together  by  strong  forceps. 
The  ligature  cuts  through  in  about  six  days,  i.  e.  that 
was  the  average  time  in  ninety  cases  of  fistula.  The 
shortest  time  has  been  three  days,  and  the  longest 
fourteen  days,  and  in  the  latter  case  a solid  portion  of 
flesh,  three  inches  in  length  and  two  inches  in  thickness, 
was  cut  through  without  any  tightening  of  the  ligature. 
You  may  be  assured  that  those  who  find  a difficulty 
in  getting  the  ligature  to  cut  quickly  and  painlessly 
are  ignorant  of  the  proper  method  of  applying  it. 

What  are  the  advantages  of  the  ligature  ? Briefly 
these,  that  in  simple  cases  there  is  little  or  no  pain 
inflicted  by  the  operation ; the  patient  can  walk  about 
without  danger.  I have  had  many  cases  proving  that 
nervous  persons  will  often  submit  to  the  ligature  when 
they  will  not  to  the  knife.  There  is  no  bleeding — a 
manifest  advantage  in  dealing  with  patients  whose 
tissues  bleed  copiously  on  incision.  I have  found  it 
useful  in  several  such  cases.  In  phthisical  cases  it  is, 
in  my  opinion,  the  best  means  of  dividing  a sinus.  In 
very  deep  bad  fistulae  the  elastic  ligature  is  most 
valuable  as  an  auxiliary  to  the  knife.  I now  most 
frequently  use  it  in  this  way — avoiding  haemorrhage 
in  sinuses  running  high  up  the  bowel  where  large 
vessels  are  inevitably  met  with.  I have  recently  had 
many  examples  of  this,  and  have  readily  and  painlessly 
divided  vascular  structures  without  anv  danger  of 

%j  O 


TREATMENT  BY  ELASTIC  LIGATURE 


33 


bleeding.  In  an  unusually  bad  case  sent  me  by  Dr 
Wm.  Price,  of  Margate,  a timid  lady  did  not  know  tbe 
ligature  had  been  used  until  it  came  away  on  the 
seventh  day,  as  she  had  absolutely  suffered  no  pain 
worth  complaining  about,  and  certainly  not  more  than 
when  the  knife  is  used  alone.  I have  now  operated 
on  eight  medical  men,  and  they  all  have  told  me  that 
there  had  been  no  pain,  and  even  very  little  discomfort 
from  the  ligature,  and  it  had  been  a great  advantage 
to  them  as  they  were  able  to  get  about  in  a moderate 
way  and  see  their  patients.  One  mistake  committed 
by  those  who  oppose  the  use  of  the  ligature  is  this, 
they  think  the  wound  does  not  commence  healing 
until  the  ligature  has  come  away — nothing  is  further 
from  the  truth.  When  the  ligature,  if  it  has  been  well 
applied,  has  cut  its  way  out,  the  wound  is  often  very 
nearly  healed.  I beg  to  refer  my  readers  to  a mono- 
graph by  Professor  Oourty,  of  Montpelier,  in  corrobo- 
ration of  my  statement.  This  gentleman  has  used  the 
elastic  ligature  frequently,  and  has  been  most  success- 
ful. Now,  what  is  the  great  objection  to  the  general 
use  of  the  ligature  in  fistula  ? It  is  this.  It  is  very 
difficult,  or  even  impossible  in  many  instances,  to  be 
absolutely  sure  that  only  one  sinus  exists.  If  there 
are  lateral  sinuses,  or  a sinus  burrowing  beneath  or 
higher  up  the  rectum  than  the  main  trunk  through 
which  you  pass  your  ligature,  the  patient  will  not  get 
well  at  one  operation.  In  these  complicated  cases  the 
knife  alone,  or  conjoined  with  the  ligature,  is  the  only 
trustworthy  remedy.  So  it  comes  about  that  surgeons 
not  very  an  fait  in  the  diagnosis  of  fistula  soon  get 
into  trouble,  and  at  once  condemn  and  throw  aside  the 
ligature. 


3 


34 


TREATMENT  BY  ELASTIC  LIGATURE 


I bad  employed  the  india-rubber  ligature  iu  only  a 
very  few  cases  before  I came  to  tbe  conclusion  that  if 
I intended  operating  frequently,  or  if  ever  tbe  method 
were  to  become  popular,  other  and  better  means  than 
those  recommended  and  used  by  Professor  Dittel  must 
be  devised  for  the  introduction  of  the  ligature  through 
the  fistula.  Professor  Dittel  has  described  several 
ways  of  accomplishing  the  end  in  view ; all  of  them 
appeared  to  be  theoretically  imperfect,  and  I found 
them  in  practice  difficult  of  performance,  tedious,  and 
exceedingly  painful  to  the  patient.  For  complete 
fistula  he  used  a probe  with  an  eye  near  its  point, 
which  was  to  be  passed  from  without  to  within,  carry- 
ing the  india-rubber  and  a strong  thread,  so  that  if 
the  india-rubber  broke  in  tying,  another  ligature  could 
be  drawn  by  the  thread  through  the  sinus.  Another 
method  was  to  pass  a tubular  probe ; through  the 
tube  a fine  wire  was  to  be  introduced,  and  the  end 
hooked  down  by  the  finger  passed  into  the  bowel ; the 
probe  was  then  to  be  withdrawn,  so  that  the  wire 
traversed  the  fistula,  one  end  hanging  from  the  outer 
opening,  the  other  emerging  from  the  anus ; the  india- 
rubber  was  then  to  be  fastened  to  the  wire  and  drawn 
through  the  fistula.  This  was  really  a very  difficult 
task  to  accomplish ; sometimes  the  wire  broke  and  the 
probe  had  to  be  reintroduced,  it  was  therefore  found 
better  to  attach  to  the  wire  a piece  of  strong  thin  cord 
and  draw  that  through  the  probe,  and  then  attach  to 
it  the  india-rubber,  which,  in  its  turn,  was  at  last  got 
into  the  desired  position.  I need  scarcely  say  that 
this  is  a very  lengthy,  as  well  as  painful,  mode  of  pro- 
cedure, as  the  thin  wire  or  cord  cuts  the  inner  opening 
of  the  fistula.  For  cases  of  incomplete  fistula  Prof. 


Fig.  3.  To  face  p.  35 

Woodcnt  showing  Mr  Allingham’s  instrument  for  drawing  the  india^ 
rubber  through  a fistula  from  within  outwards. 


It  consists  in  tlie  combination  of  a concealed  hook  or  notch  with  a blunt  or 
sharp -pointed  probe,  as  the  case  may  require,  a shows  the  curved  probe  with 
the  hook  concealed  by  the  sliding  canula,  ready  to  be  passed  through  a fistula ; or, 
if  a sharp  point  he  substituted  for  a blunt  point,  under  a tumour.  B exhibits  the 
instrument  with  the  canula  drawn  back,  and  the  previously  concealed  notch 
exposed,  ready  to  receive  the  loop  of  india-rubber ; when  this  is  placed  in  the 
notch  the  canula  is  pushed  home,  and  the  ligature  is  held  so  firmly  that  it  cannot 
escape.  Thus  a double  ligature  can  be  readily  drawn  through  a fistula  or  under  a 
tumour.  It  is  not  necessary  in  fistula  to  see  the  hook,  for  if  the  finger,  with  a 
loop  of  india-rubber  around  it,  be  passed  up  the  rectum,  the  loop  can  with  great 
facility  be  directed  over  the  end  of  the  probe  and  caught  in  the  notch  quite 
unassisted  by  vision.  C shows  the  sharp-pointed  instrument  adapted  to  the  same 
canula,  so  that  only  one  handle  and  one  canula  are  required  to  complete  the 
double  instrument. 


TREATMENT  BY  ELASTIC  LIGATURE 


35 


Dittel  recommends  a director  to  be  passed  as  far  as 
possible  up  the  sinus,  and  along  the  groove  a sharp 
needle  armed  with  the  india-rubber  is  to  be  carried  and 
the  bowel  perforated,  the  ligature  drawn  from  the  eye 
of  the  needle  by  the  finger,  and  the  needle  removed. 
This,  I may  remark,  if  the  sinus  runs  far  up  the 
bowel,  is  by  no  means  so  simple  of  accomplishment  as 
it  may  appear.  Being,  then,  very  dissatisfied  with 
these  methods  of  operating,  I set  myself  to  find  some 
better  and  simpler  plan,  and  on  reflection  I came  to 
the  conclusion  that  the  india-rubber  could  be  drawn 
much  more  readily  from  within  the  rectum  through 
the  internal  opening  (or  through  an  artificial  perfora- 
tion in  the  bowel)  than  by  commencing  to  pass  it  from 
the  external  opening.  This  conviction  led  me  to 
devise  this  simple  instrument  (which  is  shown  in  the 
woodcut)  for  drawing  a ligature  through  a fistulous 
sinus  or  beneath  a tumour,  and  Messrs  Krohne  and 
Sesemann  have  with  much  care  and  pains  rendered  it, 
in  my  opinion,  practically  quite  perfect. 

It  consists,  as  will  be  seen,  in  the  combination  of  a 
concealed  hook  or  notch,  with  a blunt  or  sharp-pointed 
probe,  as  the  case  may  require.  A shows  the  curved 
probe  with  the  hook  concealed  by  the  sliding  canula, 
ready  to  be  passed  through  a fistula,  or,  if  a sharp 
point  be  substituted  for  a blunt  one,  under  a tumour. 
B exhibits  the  instrument  with  the  canula  drawn  back, 
and  the  previously  concealed  notch  exposed,  ready  to 
receive  the  loop  of  india-rubber ; when  this  is  placed 
in  the  notch,  the  canula  is  pushed  home,  and  the  liga- 
ture is  held  so  firmly  that  it  cannot  escape.  Thus  a 
double  ligature  can  be  readily  drawn  through  a fistula 
or  beneath  a tumour.  It  is  not  necessary  in  fistula  to 


36 


TREATMENT  BY  ELASTIC  LIGATURE 


see  the  hook,  for  if  the  finger,  with  a loop  of  india- 
rubber  around  it,  be  passed  up  the  rectum,  the  loop 
can  with  perfect  facility,  and  without  the  aid  of  vision, 
be  directed  over  the  end  of  the  probe  and  caught  in 
the  notch.  G shows  the  sharp-pointed  instrument 
adapted  to  the  same  canula,  so  that  only  one  handle 
and  one  canula  are  required  to  complete  the  double 
instrument.  It  is  obvious  that  with  my  instrument  a 
double  ligature  is  carried  through  the  sinus ; this  is  an 
advantage,  for  if  the  india-rubber  breaks  as  it  is  being 
tied  there  is  a second  ligature  to  fall  back  upon.  I 
ceased,  however,  to  use  the  knot  very  soon  after 
making  trial  of  the  ligature,  and  I now  use  only  a 
small  oval  ring  of  soft  metal ; the  two  ends  of  the 
ligature  are  threaded  through  this,  the  india-rubber  is 
pulled  as  tight  as  is  required,  and  the  metal  ring  is 
then  closed  by  a strong  pair  of  forceps.  The  ring  holds 
perfectly  tight,  it  never  breaks  the  ligature,  never 
gives  way,  and  the  closure  is  effected  in  a moment. 


CHAPTER  V 


OPERATIONS  ON  FISTULA  IN  ANO 

Before  proceeding  to  operate  upon  a case  of  fistula 
it  is  highly  important  that  the  bowels  should  be  well 
cleared  out,  and  I prefer,  whenever  possible,  to  admi- 
nister a purge  three  days  prior  to  operating,  and  again 
the  night  before ; an  injection  may  also  be  given  in 
the  morning. 

The  patient  should  be  placed  on  a hard  mattress  on 
the  side  on  which  the  fistula  exists,  the  buttocks  being 
brought  quite  to  the  edge,  or  rather  overhanging  the 
edge  of  the  couch,  and  the  knees  well  drawn  up  to  the 
abdomen.  I have  no  hesitation  in  saying  that,  for  the 
majority  of  rectal  operations,  this  position  is  by  far 
the  most  convenient  both  for  the  surgeon  and  the 
patient,  but  occasionally  the  lithotomy  posture  is  pre- 
ferable, as,  for  example,  in  performing  excision  of  the 
rectum.  Now,  take  a Brodie’s  probe-director  made  of 
steel,  with  a small  probe  point ; oil  it  and  pass  it  into 
the  external  opening,  through  the  sinus  and  the  inter- 
nal opening,  if  possible ; then  insert  your  finger  into 
the  rectum,  and  on  feeling  the  point  of  the  director  in 
the  bowel,  if  the  patient  be  not  anaesthetised,  tell  him 
to  strain  down,  you  will  then  be  able  without  any 
difficulty  to  turn  the  point  out  of  the  anus.  This 


38 


OPERATIONS  ON  FISTULA  IN  ANO 


done,  the  tissues  forming  a bridge  over  the  director 
are  to  be  divided  with  a curved  bistoury. 

If  the  fistula  be  deep,  running  beneath  the  sphinc- 
ters, you  will  not  be  able  to  get  the  point  of  the  probe 
out  at  the  anus  even  if  the  patient  be  ansesthetised ; in 
such  a case  you  must  pass  the  director  well  through 
the  sinus,  then  insert  your  left  forefinger  into  the 
rectum,  steady  the  director,  and  run  a straight  knife 
along  the  groove,  cutting  carefully  towards  the  bowel 
until  the  parts  are  severed.  This  is  by  no  means  an 
easy  operation,  and  requires  much  practice  and  expe- 
rience to  accomplish  quickly  and  without  bungling. 
To  the  inexpert  surgeon  in  such  a case  I recommend 
my  deeply  grooved  director  and  scissors  which  I shall 
describe  further  on  (p.  42) ; I may  add  that  gentle 
dilatation  of  the  sphincters  under  these  difficulties 
gives  the  surgeon  an  immense  advantage  of  which  I 
now  constantly  avail  myself. 

If  there  be  no  internal  opening,  you  will  almost 
always  find  some  part  where  only  mucous  membrane 
intervenes  between  the  point  of  the  probe  and  your 
finger.  At  this  spot,  work  the  director  through,  and 
bring  down  the  point  as  before.  You  must  not  rashly 
thrust  the  point  of  the  probe  through  the  .mucous 
membrane,  or  you  will  wound  your  own  finger ; this 
accident  may  always  be  avoided  by  a little  gentle  and 
patient  manipulation,  even  when  the  tissues  are  indu- 
rated. When  you  have  divided  the  fistula  from  the 
external  to  the  internal  opening,  search  higher  with 
the  probe  for  any  sinus  running  up  beyond  the  internal 
opening ; if  this  exists  you  should  lay  it  open. 

I know  many  authorities  have  stated  that  it  is  only 
necessary  to  incise  the  fistula  between  its  external  and 


OPEKATIONS  ON  FISTULA  IN  ANO 


39 


internal  openings,  and  that  the  sinus  above  the  in- 
ternal opening  will  spontaneously  close ; my  experience 
is  most  decidedly  opposed  to  this  statement. 

In  the  great  majority  of  cases  you  will  not  cure 
your  patient  unless  you  lay  the  whole  sinus  open  from 
end  to  end.  Over  and  over  again  I have  left  the  sinus 
above  the  internal  opening  uninterfered  with,  and 
almost  invariably  have  had  to  regret  having  done  so, 
and  to  perform  a second  operation.  It  constantly 
occurs  to  me  at  St  Mark’s  to  treat  cases  which  have 
been  operated  on  at  other  hospitals,  the  upper  part  of 
the  sinus  having  been  left  and  the  patients  not  being 
cured.  In  such  cases  fresh  or  continued  burrowing 
takes  place  from  the  upper  track,  and  a second  opera- 
tion, often  more  severe  than  the  first,  is  rendered 
necessary.  It  needs  scarcely  be  said  that  in  private 
practice  this  is  very  damaging  to  the  surgeon’s  repu- 
tation. 

Having,  then,  opened  the  fistula  in  its  whole  length 
upwards,  search  for  lateral  sinuses  extending  from  the 
outer  opening ; also  see  if  there  be  any  burrowing 
outwards  beyond  the  outer  opening.  A fistulous 
orifice  is  often  not  at  either  end  of  the  sinus,  but 
somewhere  in  its  course.  Examine  carefully  to  see  if 
there  be  a secondary  sinus  running  from  and  beneath 
the  track  of  the  main  sinus.  Frequently,  in  fact  nearly 
always,  in  old  standing  cases,  the  deeper  sinus  does 
exist,  and  unless  it  is  incised  with  the  rest  the  patient 
will  not  get  well. 

Here,  again,  some  surgeons  have  asserted  that  it  is 
unnecessary  to  divide  any  but  the  principal  sinus,  for 
that  if  this  is  done  the  rest  will  heal.  On  this  point  I 
cannot  speak  too  strongly.  I am  certain  you  can 


40 


OPERATIONS  ON  FISTULA  IN  ANO 


never  guarantee  the  healing  of  a fistula  so  long  as  any 
lateral  or  deep  sinuses  remain ; and  so  long  as  they  do 
remain  fresh  sinuses  are  apt  to  form.  As  a rule  the 
best  plan  is  to  lay  open  the  original  sinus  first  and  the 
tributary  ones  afterwards. 

It  is  impossible  in  any  work  to  do  more  than  lay 
down  general  rules ; every  case  will  call  more  or  less 
upon  the  surgeon’s  knowledge,  dexterity,  and  pru- 
dence; but  in  thus  strongly  expressing  my  opinion, 
contrary  to  the  dicta  of  many  eminent  men,  I can  only 
say  that  I am  stating  what  I see  almost  every  day  to 
be  the  truth. 

When  all  the  sinuses  are  slit  up,  with  a pair  of 
scissors  take  off  a portion  of  the  overlapping  edges  of 
skin ; they  are  often  thin  and  livid,  having  very  little 
vitality.  If  not  removed,  they  will  fall  down  into  the 
wound  and  materially  retard  the  healing  process.  I 
have  frequently  induced  healing  in  a fistulous  track, 
which  had  been  only  laid  open,  by  paring  off  the  edges 
of  the  skin  which  were  undermined.  It  must  be  ob- 
served that  I am  not  advocating  “ the  cutting  out  of  a 
fistula,”  as  it  used  to  be  called ; I am  only  recom- 
mending the  removal  of  any  overhanging,  undermined, 
degenerate  skin.  When  several  sinuses  have  to  be 
laid  open,  I am  in  the  habit  of  carefully  preserving 
islets  of  skin  from  the  edges  of  which  granulations  will 
take  place,  and  by  which  cicatrisation  is  materially 
hastened.  Indeed,  I have  in  many  cases  practised  skin- 
grafting  with  good  results,  though  failures  have  not 
been  infrequent.  In  old-standing  cases,  where  there 
is  much  induration,  it  is  very  good  practice  to  draw  a 
straight  knife  through  the  dense  track  of  the  fistula, 
and  outwards  beyond  the  external  opening;  it  is 


OPERATIONS  ON  FISTULA  IN  ANO 


41 


wonderful  how  rapidly  quite  cartilaginous  hardness 
passes  away  after  this  has  been  done.  This  incision  was 
commonly  practised  by  the  late  Mr  Salmon.  He  called 
it  his  t£  back  cut,”  and  although  if  carried  to  excess 
incontinence  of  faeces  may  result,  I have  no  hesitation 
in  saying  that  Mr  Salmon  cured  many  cases  by  this 
means  where  other  surgeons  had  failed. 

Haying  completed  your  operation,  take  some  finely 
carded  cotton  wool,  and  with  a probe  pack  it  well  into 
the  bottom  of  the  wound,  packing  it  into  every  part, 
and  being  the  more  particular  about  this  if  your  in- 
cisions have  been  extensive,  or  pass  high  up  the  bowel,  ' 
or  if  the  parts  are  very  dense  and  gristly,  as  they  are 
in  old  fistulge,  and  especially  in  cases  operated  upon 
for  the  second  time.  A good  firm  pad  of  wool  should 
then  be  placed  between  the  buttocks  over  the  wounds 
and  a T-handage  firmly  applied.  With  these  precau- 
tions you  need  never  fear  haemorrhage,  for  if  the  bleed- 
ing be  thus  arrested  by  pressure  at  first  all  will  be 
well ; if,  however,  the  wool  be  carelessly  stuffed  into 
the  bowel  without  method  it  will  not  be  placed  evenly 
at  the  bottom  of  the  wound,  and  then  as  soon  as  the 
patient  rallies  from  the  shock  of  the  operation  bleed- 
ing will  recommence,  and  both  patient  and  surgeon 
will  be  put  to  much  annoyance,  and  probably  some 
anxiety.  Of  course,  if  you  see  a large  vessel  spirting 
at  the  bottom  of  a wound  it  is  best  to  close  it  by 
torsion ; when,  however,  the  track  of  the  fistula  is  very 
callous  you  cannot  twist  the  vessel,  and  a ligature  may 
then  be  applied.  By  careful  attention  to  the  details 
above  given,  a sinus  may  be  opened  to  any  possible 
distance  up  the  bowel,  or  in  any  direction  or  depth, 
without  positive  danger,  but  on  the  whole,  for  very 


42 


OPERATIONS  ON  FISTULA  IN  ANO 


deep  bad  fistulse,  the  elastic  ligature  is,  as  I have 
before  said,  generally  to  be  preferred. 

If  the  rectal  sinus  runs  up  so  high  and  the  parts 
are  so  dense  that  you  cannot  get  the  point  of  your 
probe-director  out  of  the  anus,  and  you  prefer  to  cut, 
the  safest  and  easiest  way  of  operating  is  with  the 
spring-scissors  and  special  director  designed  by  me 
and  first  made  by  Ferguson,  of  Giltspur  Street ; with 
this  instrument  you  can  divide  fistulae  high  up  the 
bowel,  however  dense  they  may  be,  with  great  facility 
and  quickness.  The  director  is  made  with  a deep 
groove,  the  section  of  which  is  more  than  three 
quarters  of  a circle ; in  this  the  globe-shaped  probe - 
point  of  one  blade  of  the  scissors  runs.  Once  placed 
in  the  groove  it  cannot  slip  out;  so,  having  passed 
your  director  through  the  sinus,  you  introduce  the 
forefinger  of  your  left  hand  into  the  bowel,  then  insert 
the  probe-pointed  blade  of  the  scissors  into  the  groove 
in  the  director,  and  run  it  along,  cutting  as  you  go, 
the  finger  in  the  bowel  preventing  the  healthy  struc- 
tures from  being  wounded.  By  this  instrument 
operations  usually  very  difficult,  and  in  which,  with- 
out great  caution,  you  are  apt  to  break  your  knife,  are 
rendered  quite  simple.  A country  hospital  surgeon 
told  me  that  after  seeing  my  description  of  this  instru- 
ment he  procured  one,  and  uses  it  in  all  his  cases  of 
fistula;  he  says  it  is  “ operating  made  easy.”  I have 
not  said  a word  about  the  old  method  of  operating, 
usually  described  in  works  on  surgery,  because  I con- 
sider the  mode  I have  detailed  so  much  more  satis- 
factory and  practicable. 

It  was  in  cases  of  sinuses  running  high  up  in  the 
rectum,  or  where  stricture  existed  in  conjunction  with 


To  face  p.  42 


Fig.  4. 

Spuing  Scissors,  with  probe  point  in  the  grooved  director.  It  should 
he  observed  that  the  scissors  can  only  be  removed  from  the  groove  by 
drawing  them  out  towards  the  handle  of  the  director. 

At  the  side  is  shown  the  strong  spring  scissors  used  at  St.  Mark’s 
Hospital  in  the  operation  upon  internal  heBmorrhoids.  Made  by  Fer- 
guson, Weiss  and  Son,  Krohne  and  Sesemann,  and  others. 


OPERATIONS  ON  FISTULA  IN  ANO 


48 


fistula  (the  internal  aperture  being  above  the  stricture) 
that  Mr  Luke,  in  the  year  1845,  recommended  cutting 
through  the  diseased  structures  by  means  of  a fine 
piece  of  strong  twine  and  a screw-tourniquet.  It  is 
an  operation  by  no  means  easy  of  performance,  but 
this  is  the  way  in  which  it  is  done,  and  it  was,  no 
doubt,  very  useful  in  some  cases.  Introduce  a hollow 
probe  through  the  sinus  and  into  the  bowel,  then  pass 
a piece  of  thin  wire  through  it,  hook  the  end  down, 
and  bring  it  out  at  the  anus ; then  withdraw  your 
probe,  fasten  the  twine  to  one  end  of  the  wire,  and 
draw  on  the  other  end.  By  this  means  you  get  the 
twine  to  traverse  the  sinus,  one  end  coming  out  at  the 
anus  and  the  other  at  the  external  opening  of  the 
fistula.  Attach  the  twine  now  to  your  tourniquet, 
and  screw  up  a little  every  day  or  two.  In  this  way 
you  may  cut  through  very  dense  structures  without 
any  great  danger;  but  the  method  is  often  painful, 
and  is  apt  to  cause  inflammation,  suppuration,  and 
fresh  abscesses.  I have  noticed  these  results  in  my 
own  practice,  and  also  in  that  of  my  colleagues.  But 
in  all  these  cases  the  elastic  ligature  is  so  very  supe- 
rior, being  more  easily  applied,  quicker  in  action,  and 
absolutely  painless,  that  I cannot  conceive  of  any  one 
using  Mr  Luke’s  tourniquet  now. 

When  the  fistula  is  complete,  wind  may  pass  through 
it,  and  also  fsoces  if  the  bowels  are  relaxed ; as  a rule, 
however,  this  symptom  does  not  occur  in  consequence 
of  the  smallness  of  the  internal  aperture,  its  situation, 
or  its  valvular  form.  It  follows  that  though  the  pas- 
sage of  wind  is  a certain  indication  of  a complete 
fistula,  the  absence  of  this  symptom  should  not  induce 
the  belief  that  there  is  no  internal  opening. 


44 


OPERATIONS  ON  FISTULA  IN  ANO 


The  most  painful  form  of  fistula,  at  the  same  time 
fortunately,  the  most  uncommon,  is  the  blind  internal 
fistula.  I have  seen  many  cases  where  the  aperture 
was  as  large  in  circumference  as  a threepenny-piece ; 
the  faeces,  when  liquid,  pass  into  the  sinus  and  create 
great  suffering — a burning  pain  often  lasting  all  day 
after  the  bowels  have  acted.  Moreover,  these  fistulae 
are  frequently  severe  in  consequence  of  the  burrow- 
ing caused  by  the  irritating  matters  which  get  into 
them. 

In  operating  upon  a blind  internal  fistula,  if  you 
can  feel,  by  the  hardness  externally,  the  site  of  the 
abscess,  you  may  plunge  your  knife  into  it,  and  thus 
make  a complete  fistula,  through  which,  of  course,  you 
pass  your  director.  If  you  cannot  feel  any  hardness 
or  see  any  discoloration  to  guide  you  to  the  situation 
of  the  sac  of  the  abscess,  the  best'  way  of  proceeding 
is  to  bend  a silver  probe-director  into  the  form  of  a 
hook,  and  then  hook  this  into  the  internal  aperture, 
and  bring  the  point  down  close  under  the  skin ; you 
then  cut  upon  it,  thrust  it  through,  and  complete  the 
operation. 

This  requires  a little  dexterity  and  some  practice  to 
manage  well,  but  it  is  by  far  the  surest  way  of  hitting 
off  the  sinus.  These  cases  of  blind  internal  fistula  are 
very  often  not  understood,  and  consequently  are  mis- 
taken for  other  diseases.  Not  infrequently  an  internal 
fistula  is  connected  with  haemorrhoids.  I have  seen 
many  such  cases.  I think  when  strong  applications 
are  made  to  haemorrhoids,  suppuration  may  be  set  up, 
and  then  an  internal  fistula  may  form.  Here  is  a case 
probably  of  that  kind. 

A gentleman  came  to  me  this  year  having  great  pain  in  the  rectum  on 


OPERATIONS  ON  FISTULA  IN  ANO 


45 


and  after  defsecation,  generally  worse  after ; sometimes  coming  on  half 
an  hour  after  leaving  the  closet.  His  history  was  that  he  had  suffered 
from  haemorrhoids,  which  came  down  and  bled,  and  that  about  seven 
weeks  before  seeing  me  he  had  undergone  an  operation  for  the  cure  of 
the  piles.  The  operation  consisted  in  thrusting  a cautery  iron  into  all 
the  piles  ; great  pain  followed,  and  he  kept  his  couch,  for  fourteen  days, 
when  he  began  to  feel  better,  and  his  piles  did  not  come  down,  but 
there  was  discharge  of  matter.  He  was  told  that  now  all  was  right, 
and  in  a few  days  he  might  go  about  as  usual,  but  after  resting  another 
week  he  still  had  pain  on  and  after  stool,  and  lost  blood.  He  went  into 
the  country,  but,  not  getting  well,  at  last  sought  my  advice.  On  passing 
my  finger  into  the  rectum,  I found  a large  deep  ulcer,  and  a sinus 
running  from  it  upwards  and  downwards ; the  piles  which  still  existed 
were  angry  and  tender,  and  very  ready  to  bleed.  As  nothing  but  an 
operation  could  cure  him,  I slit  up  the  sinuses,  drew  a straight  knife 
through  the  bottom  of  the  ulcer,  bringing  it  right  out  so  as  to  divide 
the  sphincter  freely.  I also  placed  two  fine  ligatures  around  the 
hsemorrhoids.  He  had  no  bad  symptom,  remarkably  little  pain,  and 
was  quite  well  in  five  weeks.  In  this  case,  the  thrusting  of  a fine  cautery 
set  up  suppuration,  and  caused  an  abscess,  which,  bursting,  made  a 
great  ulcer,  and  which  ulcer  formed  the  internal  opening  to  the 
sinuses. 

These  cases  of  blind  internal  fistula  are  instructive, 
I will  therefore  relate  another : 

I saw,  with  my  late  friend  Mr.  T.  Carr  Jackson,  a professional  brother 
who  had  been  suffering  for  some  time  from  pain  on  defsecation,  and 
burning  afterwards,  with  discharge  of  matter  always  upon  the  motions  ; 
he  was  also  much  troubled  with  his  water,  having  considerable  irritation 
of  the  bladder.  He  had  been  operated  upon,  but  without  getting 
better ; there  was  no  ulceration,  nor  was  there  any  fissure.  On  ex- 
amining this  gentleman  I at  once  found  what  I expected,  a small 
internal  aperture  about  two  inches  from  the  anus ; from  this  a sinus 
ran  upwards  and  downwards.  The  anus  (with  its  outside  surroundings) 
was  perfectly  healthy.  Mr.  Jackson,  assisted  by  me,  at  once  slit  up 
the  sinuses,  and  the  patient  was  rapidly  and  permanently  cured ; all 
his  bladder-symptoms  likewise  vanished. 

These  cases  of  internal  fistula  require  very  careful 
examination  to  make  a correct  diagnosis.  Often  the 
surgeon  finds  an  ulcer,  but  does  not  attempt  to  pass  a 
probe  into  it.  Truly  it  is  an  ulcer,  but  in  addition  it 


46 


OPERATIONS  ON  FISTULA  IN  ANO 


is  the  opening  of  an  internal  fistula,  which  may  burrow 
in  more  than  one  direction.  Operations  upon  internal 
fistulse  also  require  more  than  ordinary  care.  If  you 
find  an  internal  opening  in  the  bowel,  and  a sinus 
running  up  higher  from  it,  never  lay  the  sinus  open 
simply;  in  the  first  place,  if  you  do,  you  are  very 
likely,  after  you  leave  your  patient  as  you  think  quite 
safe,  to  have  some  haemorrhage  take  place,  and  the 
blood  will  be  retained  in  the  rectum  until  so  much  has 
accumulated  that  the  patient  must  pass  it.  In  such  a 
case  always  bring  your  incision  out  through  the  anus 
that  no  blood  may  be  retained.  Blood  retained  in 
the  hot  rectum  foments  the  part,  and  prevents  coagu- 
lation and  closing  of  the  vessels,  which  are  frequently 
large  and  increased  in  calibre  by  the  long-continued 
inflammation  of  the  part.  Again,  if  you  divide  an 
internal  sinus,  you  make  a deep  cavity  whence  pus  or 
discharge  can  never  thoroughly  escape,  and  in  conse- 
quence the  wound  will  not  heal. 

Whenever  you  have  to  make  an  incision  through  the 
mucous  membrane  and  into  the  submucous  tissue  in 
the  rectum,  without  continuing  your  cut  to  the  outer 
parts,  beware  of  haemorrhage.  Plug  the  rectum  well 
and  use  a styptic,  either  the  subsulphate  of  iron  or  a 
saturated  solution  of  tannin. 

I have  seen  one  death  from  this  form  of  haemor- 
rhage occur  in  the  hands  of  a very  good  surgeon,  and 
another  case  recently,  during  very  hot  weather,  in  which 
a patient  most  narrowly  escaped  with  his  life  from  a 
like  want  of  care. 

Internal  fistula,  I have  already  said,  may  commence 
by  an  ulceration  of  the  mucous  membrane ; or  perhaps 
more  rarely,  by  a small  abscess  forming  in  the  sub- 


OPERATIONS  ON  FISTULA  IN  ANO 


47 


mucous  areolar  tissue ; tliis  may  be  tbe  result  of 
wounding  or  bruising  by  hardened  faeces  or  foreign 
bodies  swallowed.  Of  this  I will  mention  two  excel- 
lent examples  I have  seen,  one  in  the  practice  of  Dr 
Cottew,  of  Hornsey;  and  the  other  in  that  of  Mr 
Kelson  Wright,  of  Brixton.  Here  two  ladies  complained 
of  considerable  pain  in  the  rectum.  On  examination 
in  each  case  a rounded  hard  swelling  was  felt  about 
an  inch  from  the  verge  of  the  anus.  On  more  care- 
fully investigating,  a very  small  orifice  was  found  run- 
ning into  this  swelling.  In  both  instances  foreign 
bodies,  i.  e.  fish  bones,  had  been  felt  by  the  medical 
attendants  before  I saw  the  patients. 

I am  decidedly  of  opinion  that  when  internal  fistula 
commences  by  ulceration  it  is  most  frequently  found 
associated  with  phthisis.  I shall  not  go  into  this 
important  question  here,  intending  to  devote  the  next 
chapter  to  the  special  consideration  of  this  subject. 

In  operating  upon  women  suffering  from  fistulas 
(especially  when  the  sinus  is  near  the  perineum),  cut 
as  little  as  possible,  for  anything  like  too  free  incisions 
are  apt  to  end  in  incontinence  of  faeces,  or,  at  all  events, 
in  such  partial  loss  of  power  in  the  sphincter  as  to  pre- 
vent the  patient  retaining  flatus,  a result  which  I need 
scarcely  say  is  a most  disagreeable  one.  I have  been 
several  times  consulted  by  ladies  on  account  of  this 
condition,  and  in  some  cases  I have  been  successful 
in  restoring  the  lost  power,  much  to  my  patients’  satis- 
faction. Of  very  great  importance  is  the  question  of 
incontinence  of  faeces  which  may  result  from  extensive 
operations  on  the  rectum  where  the  sphincter  muscles 
are  freely  divided.  A patient  who  suffers  from  inability 
to  retain  flatus  or  faeces  is  in  a most  unpleasant 


48 


OPERATIONS  ON  EISTULA  IN  ANO 


condition  ; in  fact,  some  sensitive  persons  would  not 
undergo  any  operation  which  was  at  all  likely  to  induce 
such  a state,  and  would  prefer  any  physical  suffering 
rather  than  the  perpetual  fear  of  being  in  any  way 
offensive  to  others.  It  behoves  us,  then,  to  consider 
how  much  we  dare  do  without  danger  of  damaging  or 
destroying  the  power  of  the  muscles  at  the  outer  end 
of  the  rectum.  Should  you  feel  doubtful  about  the 
preservation  of  this  power,  you  are  bound  to  tell  your 
patient  what  may  happen,  and  then  place  the  good  and 
evil  before  him ; if  you  fail  to  do  this  and  the  patient 
recovers  with  much  loss  of  the  power  of  retention,  he 
is  justified  in  complaining  of  your  treatment.  Incon- 
tinence of  wind  or  liquid  faeces  results  almost  always 
from  cutting  the  muscles,  and  principally  the  internal 
sphincter,  in  more  than  one  place.  If  you  have  a 
double  fistula,  i.e.  one  on  each  side  of  the  bowel  run- 
ning deeply  beneath  the  internal  sphincter  and  you 
divide  both  muscles,  great  loss  of  power  you  most  as- 
suredly will  have.  If  you  can  leave  ever  so  narrow  a 
ring  of  the  upper  part  of  the  band  of  internal  sphincter 
you  are  fairly  safe.  On  one  side  you  may  divide  the 
sphincters  quite  through  without  danger  if  you  will 
only  take  care  that  your  incision  is  made  quite  at 
right  angles  to  the  fibres  of  the  muscles.  If  you  divide 
the  muscles  at  all  obliquely  you  never  obtain  good 
union,  and  even  in  comparatively  slight  cases  you 
may  get  incontinence  ; I am  quite  sure  this  is  the 
secret  of  operating  in  bad  cases  without  destroying  the 
power  of  the  muscles. 

The  method  I have  adopted  in  cases  of  incontinence 
of  flatus  and  liquid  faeces  is  the  use  of  the  actual  cautery. 
I prefer  the  thermo -cautery  of  Paquelin.  By  its  judi- 


OPERATIONS  ON  FISTULA  IN  ANO 


49 


cious  application  you  can  stimulate  the  muscular  fibres 
and  cause  them  to  contract,  and  by  diminishing  the 
circumference  of  the  anus  obtain  action  of  the  fibres 
which  are  left.  I have,  now,  in  a great  many  cases 
effected  such  improvement,  if  not  cure,  as  to  earn  the 
gratitude  of  my  patients.  Some  time  back  I operated 
on  a lady  from  Doncaster.  It  was  as  bad  a fistula  as 
one  could  well  see.  Here  after  dividing  several  super- 
ficial sinuses  outside  the  anus,  I found  one  deep  sinus 
rimning  under  both  sphincters  and  up  the  bowel  beyond 
the  upper  edge  of  the  internal  muscle.  I divided  the 
sinus  with  the  elastic  ligature  (taking  care  to  cut  at 
right  angles  to  the  muscle),  the  recovery  was  perfect, 
and  not  the  slightest  loss  of  control  resulted. 

After  an  operation  for  fistula  the  bowels  should  be 
kept  confined  for  about  three  days,  a mild  purge  may 
then  be  administered,  and  full  diet  allowed.  The  wool 
usually  comes  out  when  the  bowels  act,  but  if  it  does 
not  come  away  I gently  and  gradually  remove  it. 

If  much  wool  has  been  put  into  the  rectum  to  pre- 
vent haemorrhage,  I generally  take  away  a portion  of  it 
the  next  day,  leaving  some  only  at  the  bottom  of  the 
wound.  If  the  whole  plug  is  left  in,  the  patient  will 
probably  be  very  uncomfortable,  as  he  cannot  easily 
get  rid  of  wind,  and,  the  danger  of  primary  haemor- 
rhage being  over  in  twenty-four  hours,  there  is  nothing 
gained  by  retaining  a mass  of  wool  in  the  bowel. 

Yery  little  dressing  is  required  in  the  after  treatment 
of  fistula  ; in  fact  it  is  better  to  do  too  little  than  too 
much.  If  lint,  wool,  or  any  other  foreign  body  is 
daily  thrust  into  the  wound  it  is  not  at  all  likely  to 
heal  kindly  ; a little  cotton  wadding  or  fine  oakum  laid 
quite  gently  in  the  wound  to  absorb  the  discharge  and 

4 


50 


OPERATIONS  ON  FISTULA  IN  ANO 


keep  the  edges  from  uniting,  is  all  that  is  wanted.  I 
have  constantly  seen  the  healing  process  delayed  by 
too  great  interference,  e.g.  probing,  and  putting  lint 
and  ointments  or  lotions  into  the  sore.  I very  rarely 
use  anything  but  the  dry  wool,  and  I am  no  advocate 
for  dressings  of  any  kind  ; only  when  the  wound  is 
unhealthy  or  sluggish  do  I prescribe  lotions  ; then, 
according  to  circumstances,  black  wash,  carbolic  acid, 
nitric  acid,  the  subsulphate  or  tartrate  of  iron  lotions 
may  be  advantageous.  The  compound  tincture  of 
benzoin  I have  found  to  be  an  excellent  application. 
For  the  first  few  days  I have  sometimes  employed  car- 
bolised  oil,  1 to  19,  as  it  keeps  the  wound  moist,  but 
you  must  not  go  on  long,  or  the  granulations  will  be 
destroyed  by  the  acid,  and  the  edges  of  the  wound  be- 
coming quickly  irritated,  cicatrization  will  be  thus 
retarded.  When  any  irritation  is  seen  around  the 
wound,  there  are  few  better  dressings  than  fresh  pure 
olive  oil;  it  sheathes  the  part,  is  very  soothing  and 
grateful  to  the  patient,  and  under  its  use  granulation 
goes  on  rapidly,  the  wound  is  probably  nourished  by 
the  oil,  and  there  is  a remarkably  small  quantity  of  pus 
discharged. 

Although  the  surgeon  should  not  interfere  with 
nature’s  work,  he  must  be  always  on  the  watch  during 
the  healing  process  for  any  burrowing  or  formation  of 
fresh  sinuses ; and  I wish  to  state  that  such  develop- 
ment is  generally  indicated  by  the  sudden  (and  other- 
wise unaccountable)  augmentation  of  the  purulent  dis- 
charge. Whenever  a wound  secretes  more  than  its 
surface  seems  from  your  experience  to  warrant,  be 
sure  that  burrowing  has  commenced,  and  search  dili- 
gently for  the  sinus  at  once,  for  the  longer  it  is  left 


OPERATIONS  ON  FISTULA  IN  ANO 


51 


tlie  larger  and  deeper  it  will  get.  Sometimes  it  is 
under  the  edges  of  the  wound  that  it  commences ; at 
others  at  the  end  of  the  wound  internally  or  externally, 
and  occasionally  it  seems  to  dive  down  from  the  base 
of  the  main  fistula.  When  the  sinus  is  found,  I need 
scarcely  say  that  as  a rule  it  should  be  laid  open  at  once. 
One  other  point : always  encourage  your  patient  to  tell 
you  directly  he  has  any  pain  in  or  near  the  healing 
fistula  : never  make  light  of  his  complaints ; often  he 
will  be  the  first  to  discover  by  the  existence  of  some 
unpleasant  sensation  the  commencement  of  a small 
abscess  or  sinus,  and  will  be  able  also  to  indicate  its 
situation.  While  I am  writing  this,  I have  under  my 
care  a gentleman  upon  whom  I operated  three  weeks 
ago  for  severe  fistula  on  the  left  side  and  which  has 
nearly  healed ; four  days  back  he  told  me  he  had 
slight  pain  on  the  right  buttock  three  inches  from  the 
anus.  I examined  but  could  feel  nothing,  and  my 
patient  told  me  all  his  abscesses  on  the  left  side  com- 
menced with  the  same  sort  of  pain,  and  he  felt  sure 
another  abscess  was  forming ; and  the  very  next  day  I 
detected  deep-seated  fluctuation.  I immediately  cut 
down  and  let  out  as  much  pus  as  would  fill  an  egg-cup  ; 
had  this  been  neglected  the  result  would  have  been 
serious. 

No  fixed  rules  can  be  laid  down  for  the  treatment  of 
these  wounds ; it  is  in  getting  them  to  heal  quickly 
that  the  skilful  surgeon  is  shown.  When  to  administer 
stimulants,  when  tonics,  to  feed  the  patient  well,  yet 
not  to  over-feed  him,  are  all  points  in  which  common 
sense,  practical  knowledge,  and  the  observance  of 
apparently  small  matters  will  best  guide  us.  There 
are  few  surgical  cases  that  call  more  for  intelligence 


ue  OF  ILL  LIB, 


i 


*< 

i 


52 


OPERATIONS  ON  FISTULA  IN  ANO 


and  watchfulness  on  the  part  of  the  surgeon  than  the 
after-treatment  of  a bad  fistula.  I have  often  seen 
patients  whom  the  best  and  most  eminent  surgeons  in 
London  have  utterly  failed  to  cure,  because  they  left 
the  patient  after  the  operation  almost  entirely  in  the 
hands  of  persons  who  had  not  much  experience,  and 
who  did  not  know  what  to  expect  and  guard  against. 
During  the  healing  process  do  not  purge  your  patient 
much,  but  take  care  that  the  bowels  are  fairly  re- 
lieved ; this  I generally  accomplish  by  a mild  alterative 
pill  and  some  Friedrichshall  water  or  other  gentle 
laxative. 

It  is  important  that  the  recumbent  position  should 
be  kept  for  some  time,  its  duration  must  depend  upon 
the  state  of  health  and  the  extent  and  depth  of  the 
wounds;  too  early  or  too  much  standing  or  walking 
about  will  not  only  delay,  but  sometimes  entirely  pre- 
vent cicatrization.  The  more  I see,  the  more  con- 
firmed I am  in  this  opinion.  The  sooner  you  can  get 
the  wound  to  heal  the  better,  for  it  stands  to  reason 
that  the  longer  the  wound  remains  unhealed  the  greater 
is  the  chance  that  some  fresh  abscess  or  sinus  may 
form.  You  never  ought  to  consider  your  patients 
quite  safe  until  all  sinuses  or  wounds  are  healed ; and 
if  they  go  from  under  my  care  before  that,  I always 
tell  them  they  must  take  the  responsibility  upon  them- 
selves. I do  not  keep  my  patients  long  in  bed , but  I 
make  them  recline  upon  the  sofa ; this  rule  is  especially 
advisable  in  delicate  constitutions. 

Never,  if  you  can  avoid  it,  operate  upon  a fistula 
that  is  from  any  cause  acutely  inflamed. 

While  inflammation  is  going  on,  fresh  sinuses  are 
likely  to  form,  the  areolar  tissue  breaking  down  so 


OPERATIONS  ON  FISTULA  IN  ANO 


53 


readily ; if  you  operate  under  these  conditions,  failure 
is  almost  certain  to  ensue.  All  you  ought  to  do  in 
such  a case  is  to  make  a free  dependent  opening,  and 
keep  the  patient  at  rest  until  the  inflammation  sub- 
sides, the  sac  of  the  abscess  contracts,  and  the  forma- 
tion of  sinuses  is  for  a time  completed ; then,  and  only 
then,  your  operation  stands  a fair  chance  of  suc- 
ceeding. 

In  old-standing  cases  of  ulceration  and  stricture  of 
the  rectum,  fistulse  almost  invariably  form,  but  the 
internal  opening  is  very  rarely  above  the  stricture, 
where  one  would  think  it  ought  to  be ; sometimes  it 
opens  into  the  stricture  itself,  but  nearly  always  nearer 
the  anus  than  the  stricture.  The  treatment  of  these 
cases  will  be  considered  in  the  chapters  on  Stricture 
and  Ulceration. 

It  is  a rule  with  me  never  to  despise  a small  fistula, 
more  especially  if  it  be  directly  dorsal  or  perineal; 
often  when  you  divide  a seemingly  most  trivial  sinus, 
you  find  from  the  opened  track  a deeper  one  passing 
up  the  bowel,  and  this  condition,  as  I have  pointed 
out,  is  an  obstacle  to  the  success  of  the  elastic  liga- 
ture. 

Moreover,  when  this  is  not  the  case,  slight  fistulas 
are  not  rarely  difficult  to  heal.  I have  been  many 
times  much  troubled  by  them,  and  generally  in  cases 
where  they  ran  through  the  fibres  of  the  external 
sphincter,  and  not  quite  beneath  them,  so  that  in 
operating  only  a portion  of  that  muscle  was  divided. 
The  late  Mr  Salmon  was  in  the  habit  of  saying  when 
he  had  laid  open  one  of  these  fistulae  : “ How  I have 
made  a fissure,  and  I shall  proceed  to  cure  it,”  and  he 
then  drew  his  knife  along  the  base  of  the  sinus  so  as 


54 


OPERATIONS  ON  FISTULA  IN  ANO 


to  entirely  divide  the  external  sphincter.  Mr  Salmon 
was  a man  of  very  acute  observation,  and  I am  sure  in 
many  such  instances  this  practice  is  the  best  that  can 
be  adopted.  I do  not  say  it  is  always  necessary  to 
make  a deep  incision  through  the  sphincter,  but  I 
always  make  one  through  the  muscle  in  superficial 
dorsal  fistuhe,  and  I am  confident  if  you  neglect  this 
precaution  you  will  often  have  difficulty  in  healing 
these  apparently  very  trivial  sores.  If  they  do  not 
cicatrize  quickly  they  become  very  much  like  fissures 
in  appearance,  and  the  patient  will  suffer  pain  more  or 
less  severe  after,  as  well  as  at  the  time  of,  defsecation. 
Here  is  an  illustrative  case  : 

A gentleman  had  been  operated  upon  by  one  of  my 
colleagues  for  fistula  and  got  well,  but  after  some 
months  another  abscess  formed  in  the  site  of  the 
old  wound ; this  burst.  When  I saw  him  there  was  a 
very  small  fistula,  nearly  dorsal,  not  deep,  but  tunnel- 
ling under  the  old  scar ; I opened  this — in  a fortnight 
it  had  not  healed — no  burrowing  had  taken  place.  I 
touched  the  sore  with  nitrate  of  silver,  and  ordered 
him  some  nitrate  of  mercury  and  opium  ointment,  but 
still  it  did  not  heal,  and  in  another  fortnight  he  began 
to  complain  of  pain,  lasting  an  hour,  more  or  less, 
after  the  bowels  acted.  I now  saw  that  without  a freer 
use  of  the  knife  it  would  not  heal  at  all,  and  might, 
and  probably  would,  get  deeper ; so  I persuaded  him 
to  lay  up  for  a few  days,  and  I drew  a fissure  knife 
along  the  wound,  beginning  above  it,  and  coming 
below  the  external  end  of  it,  and  I took  care  to  go 
right  through  the  sphincter.  This  proceeding  settled 
the  matter  : in  about  a fortnight  he  was  quite  well,  and 
he  has  remained  so.  This  case  made  a deep  impression 


OPERATIONS  ON  FISTULA  IN  ANO 


55 


upon  me,  as  I saw  that  the  slight  incision  through  the 
base  of  a fistula  in  this  class  of  case  is  of  no  moment 
when  you  are  operating,  and  it  may  save  you  some 
anxiety,  and  perhaps  discredit  also,  afterwards. 

Here  is  another  case  : 

A gentleman  with  an  apparently  very  small  fistula, 
situated  anteriorly,  went  to  an  eminent  surgeon  ; it  was 
so  slight  that  the  surgeon  recommended  him  to  be 
operated  upon  at  once  in  his  consulting-room ; this 
was  done  and  the  patient  went  home.  After  five 
weeks,  the  wound  not  having  healed,  I was  requested 
to  see  the  patient,  and  I found  that  from  the  bottom 
of  the  small  wound  there  ran  a deep  sinus  up  the 
bowel  and  also  forwards  nearly  to  the  scrotum.  I do 
not  say  that  these  sinuses  might  not  have  formed 
since  the  first  operation,  but  the  case  clearly  shows 
how  careful  one  ought  to  be  both  in  diagnosis  and 
prognosis.  A certain  cure  had  been  promised  in  this 
case  in  a few  days. 


CHAPTER,  VI 


FISTULA  IN  CONJUNCTION  WITH  PHTHISIS 

From  a surgical  point  of  view  I wish  to  consider 
phthisis  as  a complication  of  fistula.  It  would  doubt- 
less be  more  correct  to  regard  fistula  as  one  of  the 
complications  of  phthisis,  but  I think  it  better  for  my 
purpose  to  put  it  in  the  way  I have. 

This  subject  is  one  of  considerable  importance,  and 
has  scarcely,  I think,  received  from  any  author  the 
attention  it  deserves.  The  majority  of  writers  upon 
fistula  have  simply  expressed  the  opinion  that  in 
phthisical  patients  no  interference  should  be  attempted 
with  the  fistula,  generally  contenting  themselves  by 
stating  that  if  any  operation  be  performed  the  wounds 
will  not  heal  and  the  patient’s  life  will  be  shortened. 
It  is  the  opinion  of  some  eminent  men  that  fistula  has 
really  the  power  of  arresting,  or  at  all  events  retarding 
the  chest  affection,  and  on  that  ground  they  would 
deprecate  any  operation.  This  opens  up  a very  in- 
teresting question,  which  I shall  endeavour  presently 
in  some  degree  to  pursue. 

There  are  other  authorities  of  great  experience  in 
consumption  who  have  expressed  the  belief  that  the 
co-existence  of  fistula  and  phthisis  is  by  no  means  a 


FISTULA  IN  CONJUNCTION  WITH  PHTHISIS  57 

common  one.  Andral  and  Louis  both  state  that  they 
had  very  rarely  observed  a conjunction  of  the  diseases. 
Andral  in  fact,  says,  that  out  of  800  patients  affected 
with  phthisis  he  noticed  only  one  case  of  fistula. 
According  to  Louis  tubercular  ulceration  is  very 
common  in  the  small  intestine,  and  but  very  rarely 
found  in  the  colon  and  rectum.  The  same  doubt  as  to 
the  prevalence  of  fistula  in  phthisis  has  been  expressed 
to  me  by  eminent  physicians  whose  opportunities  of 
seeing  pulmonary  affections  have  been  most  extensive. 
Upon  this  point  I beg  to  make  an  observation : — I 
have  not  the  slightest  doubt  that  there  are  immense 
numbers  of  phthisical  persons  in  whom  no  fistulse  exist, 
but  I have  also  no  doubt  that  there  is  a very  large 
number  of  cases  of  fistula  in  which  there  is  tubercular 
disease  of  the  lungs. 

A patient  with  disease  of  the  lungs  going  to  any  of 
the  hospitals  for  phthisis  does  not  say  anything  about 
his  fistula  to  the  attending  physician — he  speaks  only 
of  his  chest ; but  the  same  man  comes  to  me  at  St 
Mark’s  saying  that  he  has  a fistula ; I perceive,  per- 
haps at  once,  that  he  is  consumptive.  Of  course  the 
physician  cannot  see  that  the  phthisical  patient  has  a 
fistula,  and  the  question  is  very  rarely  put;  of  this 
I am  certain,  as  patients  say,  “ I am  attending  at  such 
a hospital  for  my  cough.”  When  I ask,  did  you  tell 
the  gentleman  you  saw,  that  you  had  fistula?  their 
reply  almost  universally  is  “ No,  sir,  I did  not.” 

For  my  own  part  I am  quite  convinced  that  a very 
considerable  percentage  of  fistulous  patients  have  more 
or  less  of  tubercular  lung  affection.  I have  endea- 
voured to  find  out  what  the  percentage  is,  and  I have 
carefully  gone  over  a period  of  seven  years  in  private 


58  FISTULA  IN  CONJUNCTION  WITH  PHTHISIS 

practice,  from  1871  to  1877  inclusive,  and  I find  that 
out  of  792  cases  of  fistula  seen  by  me  during  that 
period,  124  had  phthisis  either  active  or  latent,  or 
such  symptoms  as  foreshadowed  the  appearance  of 
phthisis,  such  for  example  as  narrow  and  flat  chests, 
winter  cough,  continuing  long  through  the  spring, 
proneness  to  take  cold,  feeble  circulation,  and  incapa- 
bility for  sustained  physical  exertion,  also  that  facial 
expression  which  is  not  uncommon,  and  I will  add  that 
a bad  family  history  was  frequently  co-existent.  In 
the  years  1878,  79,  and  80,  I saw,  in  private  practice, 
840  cases  of  fistula,  and  of  these  110  had  symptoms  of 
phthisis. 

I will  here  quote  the  opinions  of  those  entitled  to 
respect  on  the  question  of  operation  on  phthisical 
patients. 

Dr  Bushe,  of  America,  in  his  really  admirable 
treatise  observes,  66  It  is  very  apparent  that  a great 
many  fistulse  depend  upon  disease  of  the  lungs,  there- 
fore we  should  not  operate  upon  them,  else  the  healing 
will  give  rise  to  an  increase  of  the  pulmonary  disorder 
and  curtail  life.” 

Mr  Quain  says,  “ When  the  symptoms  of  tubercular 
disease  of  the  lungs  are  present  the  operation  for 
fistula  is  not  allowable.” 

Mr  Curling  does  not  express  any  opinion  upon  the 
question  of  operation,  although  he  notices  the  frequent 
concurrence  of  the  two  maladies. 

Mr  Erichsen  in  his  6 System  of  Surgery  ’ objects  to 
the  operation  save  in  a few  picked  cases. 

In  c Holmes’  System  of  Surgery’  the  subject  is  dis- 
missed with  this  observation  : — “ If  a fistula  be  cut 
when  a patient  is  suffering  from  phthisis,  the  wound, 


FISTULA  IN  CONJUNCTION  WITH  PHTHISIS 


59 


in  the  majority  of  cases,  will  not  heal.”  This  I am 
bound  to  say  is  not  my  experience. 

Miller  says,  “ In  phthisical  cases  the  wound  in  all 
probability  would  not  heal,  and  supposing  that  it  did 
heal,  the  result  would  probably  be  most  injurious  on 
the  system,  the  pulmonary  disease  advancing  with 
fresh  virulence  on  the  closing  up  of  an  outlet  whence 
purulent  and  other  products  had  been  long  habitually 
discharged.” 

Dr  Theophilus  Thomson  states  that  the  co-existence 
of  fistula  with  phthisis  appears  to  retard  the  progress 
of  the  latter  disease,  acting  as  a derivative. 

In  the  recent  works  on  phthisis  to  which  I have  had 
access  there  is  no  reference  made  to  the  subject  I am 
treating. 

Dr  Bristowe,  while  mentioning  the  frequency  of 
tubercular  ulceration  of  the  large  and  small  intes- 
tines, does  not  allude  to  fistula  in  conjunction  with 
phthisis. 

When  we  find  an  opinion  so  decidedly  and  generally 
expressed  by  men  of  acknowledged  ability  and  expe- 
rience of  the  subject  on  which  they  treat,  we  very 
naturally  and  properly  hesitate  to  call  in  question  their 
judgment;  but,  on  the  other  hand,  we  should  never  be 
prevented  from  inquiring  carefully  and  diligently  as 
to  the  grounds  upon  which  that  conclusion  has  been 
based ; and  should  opportunities  present  themselves  we 
should  test  whether  the  opinion  is  founded  on  fact.  I 
have  always  thought  that  an  universally  wide-spread 
belief,  though  perhaps  exaggerated  or  distorted,  has 
some  considerable  element  of  truth  which  had  served 
for  its  origination,  but,  at  the  same  time,  there  is 
nothing  more  likely  to  lead  to  error  and  stifle  the 


60 


FISTULA  IN  CONJUNCTION  WITH  PHTHISIS 


spirit  of  inquiry  than  a too  easy  acquiescence  in  what 
may  be  called  “ popular  creeds.” 

It  must  be  obvious  to  everybody  that  to  operate 
upon  a patient  with  confirmed  and  advanced  tuber- 
culosis would  be  a positive  cruelty,  and  would  un- 
doubtedly hasten  his  inevitable  fate ; but  there  are 
different  forms  of  phthisis,  some  evidently  not  so 
destructive  as  was  formerly  imagined ; and  we  know 
that  many  persons  whose  chests  at  one  period  of  their 
lives  exhibited  undoubted  signs  of  breaking  down  of 
pulmonary  tissue,  the  formation  of  cavities,  &c.,  ulti- 
mately recover,  and  attain  a fair  old  age.  Every  sur- 
geon who  has  been  much  in  the  post  mortem  room, 
must  be  familiar  with  the  fact  that,  in  old  persons 
who  have  not  died  of  phthisis,  repaired  vomicae  and 
cretification  of  deposits,  probably  tubercular,  are  not 
uncommonly  found.  I am  quite  certain  that  there  are 
many  sufferers  from  lung  affections  complicated  by 
fistula,  who,  because  they  are  said  to  be  phthisical, 
have  nothing  done  for  the  cure  of  their  fistulae,  and 
whose  lives,  in  consequence,  are  rendered  much  more 
wearisome  and  wretched  than  they  might  have  been  if 
an  operation  had  been  judiciously  performed. 

For  my  own  part,  I do  not  think  we  have  many,  if 
any,  clinical  facts  tending  to  show  that  the  operation 
for  fistula  in  phthisical  patients  renders  the  lung  affec- 
tion worse,  or  makes  it  more  rapidly  progressive.  In 
saying  this  I must  not  be  understood  to  advocate 
wholesale  indiscriminate  operations  upon  tuberculous 
patients ; but  I mean  that  if  care  be  taken  in  the 
selection  of  the  proper  cases,  avoiding  interference,  if 
possible,  with  rapidly  advancing  phthisis,  and  the 
operation  be  performed  discreetly  at  the  right  time  of 


FISTULA  IN  CONJUNCTION  WITH  PHTHISIS 


61 


the  year,  and  with  favorable  surroundings,  the  patients 
will  generally  do  well,  and  be  benefited,  and  not 
damaged,  by  the  cure  of  their  rectal  malady. 

I have  had  several  cases,  which  certainly  at  first 
sight  appeared  to  contradict  what  I have  just  stated, 
and  I will  relate  an  example : 

A man,  set.  35,  was  admitted  into  St  Mark’s  Hos- 
pital in  the  spring  of  1867.  He  was  not  absolutely  an 
unhealthy-looking  man,  but  he  was  delicate  : he  was 
dark  and  hirsute,  moderately  well  nourished;  the 
chest  was  fully  developed,  there  was  no  dulness  on 
percussion.  He  had  never  spat  blood,  but  was  very 
liable  to  cold,  and  always  had  a winter  cough.  He 
had  a fistula  of  the  blind  internal  variety,  which  caused 
him  a good  deal  of  suffering,  the  aperture  in  the  bowel 
being  large  and  open. 

How,  had  this  man  not  been  in  much  pain,  in  all 
probability  I should  not  have  operated  upon  him,  or 
at  all  events  I should  have  postponed  doing  anything 
until  the  summer  had  more  advanced,  as  I really  did 
not  at  all  like  the  look  of  him,  but  I thought  his  case 
warranted  an  operation,  the  more  especially  as  it  did 
not  seem  that  a severe  one  was  necessary.  Three 
days  after  the  operation  he  was  attacked  with  diffi- 
culty of  breathing,  and  on  examination  it  was  found 
that  there  was  pneumonia  of  the  upper  part  of  the 
right  lung ; two  days  later  than  this  he  had  an  acute 
attack  of  haemoptysis ; after  a time  he  got  better,  but 
there  was  evidence  of  breaking  down  of  lung  tissue. 
As  soon  as  possible  I sent  him  out  of  the  hospital  to 
go  into  the  country;  he  returned  much  better,  with 
the  fistula  fairly  healed,  but  I am  afraid  that,  as  far  as 
his  chest  was  concerned,  he  was  in  a bad  way. 


02 


FISTULA  IN  CONJUNCTION  WITH  PHTHISIS 


Altogether,  I have  had  twenty-five  such  cases  in 
hospital  practice  exactly  resembling  the  one  I have 
related,  so  much  so,  indeed,  that  it  is  unnecessary  to 
give  them  in  detail.  The  general  circumstances  are 
these  : — A fistula,  in  a not  very  consumptive-looking 
patient,  suspicious  appearance  and  history  being  all 
that  can  be  made  out.  The  patient  is  operated  upon, 
and  in  four  or  five  days  inflammation  of  a lung  and 
haemoptysis  set  in,  this  being  in  nearly  all  the  cases 
the  first  attack.  Now,  one  is  not  unnaturally  led  to 
conclude  that  the  operation  is  the  active  cause  of  the 
sudden  accession  of  the  lung  symptoms  in  these  cases ; 
but  after  all  it  may  not  be  so ; there  are  other  factors 
to  be  considered.  These  may  be  mentioned : the 
natural  excitement  preceding  and  attending  the  opera- 
tion ; the  effect  of  anaesthetics ; the  different,  and  pro- 
bably colder  and  “ draughty  ” air  of  the  hospital 
wards  ; and  the  sudden  taking  to  the  recumbent  position , 
by  which,  in  lungs  predisposed  to  disease,  hypostatic 
engorgement  may  be  readily  set  up,  and  pneumonia 
follow.  This  last  I think  a very  important  element  in 
the  phenomena;  and  from  this  I draw  a lesson — never 
confine  your  patients  who  have  a consumptive  ten- 
dency entirely  to  bed.  I let  them  recline  on  the  sofa, 
and  sit  on  air  cushions  from  the  day  of  the  operation, 
and  I really  think  this  precaution  has  a great  deal  to 
do  with  the  result.  You  may  accept  it  as  a fact  that 
phthisical  hospital  patients  do  not  do  nearly  so  well  as 
phthisical  private  patients  : and  good  feeding,  nursing, 
and  the  comforts  of  a home,  may  be  credited  to  a great 
extent  with  the  causation  of  the  difference. 

Those  gentlemen  who  object  to  operating  in  any 
case  upon  a phthisical  patient,  give  different  and  rather 


FISTULA  IN  CONJUNCTION  WITH  PHTHISIS 


63 


contradictory  reasons  for  their  objections.  Some  say 
“ Do  not  operate,  for  the  wound  will  not  heal,  and  the 
increased  discharge  will  be  detrimental;”  others,  “ The 
healing  of  the  fistula  will  be  injurious  to  the  patient, 
as  the  discharge  prevents  or  retards  the  progress  of 
the  chest  affection.”  I have  this  remark  to  make 
here ; that  when  a fistula  has  kindly  healed  I never 
knew  a phthisical  patient  to  be  directly  the  worse  for 
it,  i.e.  I have  never  seen  the  chest  affection  aggravated 
or  suddenly  get  worse  on  the  closing  up  of  the  wound. 
I think  the  idea  that  the  discharge  retards  the  pro- 
gress of  the  lung  disease  is  rather  a remnant  of  the 
old  doctrine  of  issues,  setons,  and  derivatives,  than  a 
positive  fact. 

Although  I say  that  hospital  patients  do  not  as  a 
rule  do  well,  yet  I have  had  many  satisfactory  results, 
even  where  such  could  hardly  have  been  anticipated. 
I will  detail  some. 

A man,  set.  29,  was  admitted  into  the  hospital  under  my  care ; he  had 
decided  dulness  at  the  apex  of  the  left  lung,  and  had  spat  blood  fre- 
quently, and  always  had  winter  cough.  He  had  a complete  fistula, 
with  a very  patulous  and  large  internal  orifice,  into  which  fseces  were 
constantly  passing,  and  he  consequently  suffered  much,  and  was  very 
anxious  to  obtain  relief.  On  this  ground  I determined  to  operate.  I 
did  not  confine  him  to  bed  more  than  a few  days.  I fed  him  well,  and 
gave  him  cod  liver  oil  and  tincture  of  the  muriate  of  iron  during  the 
treatment,  and  I kept  him  in  the  hospital  only  for  nine  days.  He  did 
very  well,  the  wound  healed,  and  as  I have  seen  him  since,  I know  that 
his  chest  affection  has  not  progressed. 

Here  is  a very  unfavorable  case  winch,  by  a little 
cautious  treatment,  did  well  in  the  end. 

A police  constable,  set.  29,  came  to  St.  Mark’s  in  the  summer  of 
1867  ; eight  weeks  previously  he  had  been  operated  upon  for  fistula 
at  St  Mary’s  Hospital.  He  was  undoubtedly  consumptive;  some 
time  ago  had  haemoptysis;  he  sweated  at  night,  and  was  very  thin 


64 


FISTULA  IN  CONJUNCTION  WITH  PHTHISIS 


and  feeble.  On  examination  an  unhealthy  wound  was  to  be  seen 
involving  the  bowel;  the  edges  overhung,  were  livid,  and  irregularly 
ulcerated;  the  mucous  membrane  of  the  bowel  was  undermined 
to  the  extent  of  two  inches  upwards.  A deep  incision  had  been  made 
through  the  sphincter,  and  he  had  no  power  to  retain  wind,  or  his 
motions  if  at  all  relaxed.  He  coughed  a good  deal,  and  expectorated 
freely  ; he  was  very  depressed  in  spirits.  It  is  difficult  to  conceive  a 
more  lamentable  failure  of  an  operation ; he  was  in  all  respects  mate- 
rially worse  for  what  had  been  done.  I scarcely  think,  had  I seen 
the  man  at  first,  I should  have  interfered  with  him  at  all.  The 
question  was  what  could  be  done.  Finding  that  he  had  friends  in  the 
country  I advised  his  going  away,  and  told  him  to  live  in  the  open  air 
all  day  long,  to  drink  as  much  milk  and  cream  as  his  stomach  would 
digest,  and  to  take  a teaspoonful  of  cod-liver  oil,  and  fifteen  drops 
of  the  muriated  tincture  of  iron,  three  times  in  the  day.  He  had 
never  been  able  to  take  the  oil,  but  I managed  to  overcome  his  repug- 
nance by  giving  him  one  drop  of  nitro-benzole  with  every  dose,  for 
which  hint  I am  indebted  to  my  friend  Dr.  Stone,  of  St.  Thomas’s 
Hospital.  The  patient  came  back  in  about  six  weeks  very  much  im- 
proved in  general  health ; he  had  gained  weight  and  strength.  His 
wound  looked  healthier,  but  intrinsically  was  in  much  the  same  condi- 
tion. I now  did  not  dare  to  take  him  into  the  hospital,  fearing  the  con- 
finement and  air ; but  I thought  something  might  be  done  to  alleviate 
his  condition  ; so  I pared  off  the  overhanging  and  devitalized  edges  of 
the  skin,  and  laid  open  the  sinus  under  the  mucous  membrane ; I did 
not  confine  him  to  bed  at  all.  A few  days  after  doing  this  I painted 
over  the  sluggish  base  of  the  wound  with  blistering  fluid,  and  thus  got 
the  whole  wound  to  granulate.  After  about  five  weeks  it  healed ; he 
recovered  very  considerable  power  in  the  sphincter,  and  altogether  was 
in  a wonderfully  more  favorable  condition  than  when  I took  him  in 
hand.  To  show  what  an  improved  state  of  health  he  was  in  I can  state 
that  he  was  able  the  whole  of  the  following  winter  to  take  his  turn  of 
night  duty  without  being  once  on  the  sick  list. 

There  is  a circumstance  which  occasions  me  some- 
times to  interfere  in  a case  of  fistula  in  phthisical 
patients,  and  that  is,  the  mental  depression  which  the 
rectal  affection  creates.  Frequently  the  sufferer  thinks 
much  more  about  his  fistula  than  he  does  about  what 
he  calls  “his  little  cough,”  and  is  quite  dismayed  and 
brought  to  despair  when  you  tell  him  that  you  cannot 


FISTULA  IN  CONJUNCTION  WITH  PHTHISIS 


65 


do  anything  to  cure  him.  I am  certain  that  few 
things  conduce  more  to  the  rapid  progress  of  phthisis 
than  mental  anxiety  and  loss  of  hope. 

As  illustrating  this  I will  relate  the  case  of  a young 
man  named  Henry,  who  came  to  me  at  St  Mark’s 
in  the  year  1866. 

He  was  in  great  mental  distress  because  of  a fistula,  for  which  a 
well-known  surgeon  had  told  him  nothing  could  be  done  as  he  was 
consumptive.  It  was  true  that  this  man  had  suffered  from  haemoptysis 
some  time  ago,  and  looked  far  from  being  a promising  patient ; more- 
over his  family  history  was  unsatisfactory.  On  examining  him  I found 
that  his  fistula  was  evidently  a phlegmonous  one,  and  not  scrofulous, 
i.e.  it  began  as  an  abscess,  ran  an  acute  course,  opened  externally,  and 
did  not  communicate  with  the  bowel,  so  I thought  I could  operate  upon 
him  with  safety.  The  mere  fact  of  his  belief  that  he  would  get  rid  of 
a most  troublesome  and  annoying  disorder  rallied  him  at  once.  The 
day  following  the  operation  he  looked  much  better  than  he  had  done 
before  it,  and  without  any  interruption  he  quickly  got  well.  I watched 
the  man  for  more  than  twelve  months,  and  most  assuredly  his  lung 
symptoms  had  made  no  marked  advance. 

I relate  cases  which  occurred  some  years  since,  be- 
cause we  have  the  opportunity  of  seeing  how  they 
terminated. 

In  the  spring  of  1866  I operated  upon  a gentleman,  a patient  of  Mr 
Burroughs,  of  Lee.  He  was  decidedly  but  not  hopelessly  phthisical ; 
the  undermining  of  skin  in  this  case  was  very  considerable,  and  he 
suffered  so  much  that  I had  not  the  least  doubt  about  the  propriety  of 
attempting  to  relieve  him.  The  wound  was  large,  but  we  had  really  no 
difficulty  in  getting  it  to  heal.  I saw  a relative  of  this  patient  lately 
who  informed  me  that  he  continued  well  and  had  no  return  of  the 
fistula.  I believe  in  this  case  the  chest  symptoms  were  absolutely 
benefited  by  the  operation. 

A young  man  was  brought  to  me  by  his  friends  in  August,  1864.  He 
was  twenty  years  of  age,  and  had  a decidedly  phthisical  appearance ; 
he  had  a circumscribed  flush  on  his  cheeks ; was  thin,  and  had  a rapid, 
feeble  pulse ; he  was  a railway  clerk,  and  had  been  leading  a rather 
irregular  life  for  twelve  months  previous  to  his  present  illness ; he  had 
never  suffered  from  haemoptysis  to  any  extent,  but  had  spat  mucus 
streaked  with  blood  not  infrequently.  There  was  some  dulness  over  the 

5 


66 


FISTULA  IN  CONJUNCTION  WITH  PHTHISIS 


apex  of  the  left  lung,  and  feeble  inspiratory  murmur.  He  took  cold  on 
the  slightest  provocation  ; he  had  lost  a sister  by  consumption,  and  also 
his  maternal  aunt  ; his  mother  was  far  from  a healthy -looking  woman ; 
but  his  father  was  strong  and  had  no  tendency  to  pulmonary  disease. 
This  was  a case  I would  willingly  not  have  interfered  with,  but  tbe 
patient  was  suffering  so  much  that  I determined  to  try,  after  improving 
his  health,  what  I could  do  for  him.  The  fistula  commenced  last 
Christmas  as  an  abscess,  which  opened  spontaneously.  When  I first 
saw  him,  he  had  a sinus  on  one  side  of  the  bowel  and  an  unopened 
abscess  on  the  other  side,  and  was  suffering  a good  deal  of  pain.  The 
abscess  I opened  at  once.  I put  him  on  cod-liver  oil  and  tinct.  ferri 
muriatis,  and  soon  sent  him  away  into  the  country.  He  returned  very 
much  better  in  health,  but  the  sinus  had  burrowed  round  behind  the 
anus  and  joined  the  abscess  I had  opened,  thus  forming  the  not  un- 
common horse- shoe  fistula.  He  was  now  importunate  for  something 
to  be  done,  and  although  I was  very  dubious  about  the  result,  I yielded 
to  his  wishes.  There  was  one  good  point  in  his  case  which  encouraged 
me,  and  that  was,  the  discharge  was  tolerably  healthy.  On  the  23rd 
of  September  I operated,  not  making  more  incisions  than  were  neces- 
sary, but  freely  removing  the  over-lapping  edges  of  skin.  He  took  full 
diet — wine,  beer,  and  anything  he  fancied — from  the  day  of  the  opera- 
tion, and  (with  the  exception  of  a little  burrowing  under  the  skin 
towards  the  perineum,  which  I was  obliged  to  lay  open)  he  made  a good 
recovery.  On  the  10th  of  November  he  was  quite  well,  and  was  weighed, 
and  showed  an  increase  of  fourteen  pounds  since  the  operation.  This 
lad  died  of  phthisis  three  years  after.  The  fistula  never  recurred,  and 
for  more  than  two  years  he  enjoyed  fair  health. 

In  the  year  1867  I operated  upon  a patient  who  was  a very  delicate 
and  decidedly  consumptive  person;  he  suffered  much  from  winter 
cough,  and  had  spat  blood  several  times  ; there  was  a history  of  phthisis 
in  his  family.  His  fistula  was  a complete  one  and  caused  him  a great 
deal  of  pain  and  inconvenience,  interfering  most  materially  with  his 
taking  any  walking  exercise.  I operated  upon  him,  and  was  a few 
weeks  later  compelled  to  lay  open  another  sinus,  which  had  either 
formed  since  or  been  overlooked  by  me.  The  wounds  were  slow  in 
healing,  and  required  a good  deal  of  attention,  but  finally  they  cicatrized 
soundly,  and  the  patient’s  health  was  much  benefited  by  his  freedom 
from  pain  and  his  renewed  capability  of  walking.  I saw  this  gentle- 
man very  lately,  he  is  still  delicate,  but  enjoys  a fair  amount  of  health, 
and  the  fistula  remains  still  healed  most  assuredly  he  has  not  been 
damaged  by  what  was  done  for  him. 


Eleven  years  after  the  operation. 


FISTULA  IN  CONJUNCTION  WITH  PHTHISIS 


67 


I operated  some  four  years  ago  upon  a patient  who  was  under  the 
care  of  Dr  Palfrey  and  Dr  G.  Fowler  of  Kennington.  This  gentleman 
had  undoubted  phthisis  with  vomicse  in  his  lungs,  and  at  the  same  time 
he  suffered  so  much  from  an  internal  fistula  with  a large  opening  that 
I felt  compelled  to  try  and  relieve  him.  Accordingly,  with  the  concur- 
rence of  Drs  Palfrey  and  Fowler,  I opened  the  fistula.  The  wound 
slowly  but  surely  healed,  and  from  the  day  of  the  operation  he  lost  his 
pain,  and  lived  about  two  years  in  comparative  comfort — a longer  time 
than  was  anticipated  by  his  medical  attendants. 

I saw,  in  conjunction  with  Dr  Wilson  Fox,  a gentleman  about  28 
years  of  age,  who  had  been  some  time  in  India,  and  who  had  suffered 
from  pleurisy  and  pneumonia,  associated  with  the  deposit  of  tubercle  ; 
he  also  had  a complete  fistula,  which  gave  him  great  inconvenience  and, 
‘at  times,  pain.  He  was  very  anxious  to  have  something  done  for  this, 
and  Dr  Fox,  as  his  lung  condition  was  stationary  and  no  active  disease 
present,  was  of  opinion  that  there  was  no  objection  to  an  operation  on 
the  fistula  ; I therefore  cut  through  the  sinus  with  the  elastic  ligature 
without  occasioning  the  patient  any  pain  or  confining  him  more  than 
forty- eight  hours  to  his  room ; four  days  sufficed  for  the  ligature  to  cut 
through,  and  the  wound  soon  healed,  the  patient  experiencing  great 
comfort.  After  about  eight  months  he  caught  a cold,  and  his  chest- 
symptoms  recurred  with  much  cough,  and  the  cicatrix  of  the  wound  in 
the  part  near  the  anus  broke  down,  but  this  did  not  trouble  him  much 
and  from  time  to  time  the  wound  healed  and  reappeared ; but  there 
was  no  doubt  in  the  mind  of  the  patient  as  to  the  advantage  of  the 
operation,  and  Dr  Fox  could  not  say  that  any  disadvantage  had 
accrued.  The  patient  was  one  of  those  men  who  never  will  take  care 
of  themselves,  and  who  habitually  smoke  and  drink  too  much.  With 
all  those  drawbacks,  two  years  after  the  operation  he  was  still  living. 

The  question  of  cough  is  a very  important  one  when 
weighing  the  probabilities  of  an  operation  doing  well 
or  ill.  I believe  that  severe  or  frequent  cough,  no 
matter  from  what  it  arises,  is  most  inimical  to  the 
well-doing  of  the  patient. 

A medical  man  came  from  the  country  a short  time 
ago  to  be  operated  upon  by  me  for  a complete  fistula ; 
there  was  not  the  least  suspicion  of  phthisis,  but  he 
had  a bad  cough.  I advised  him  to  get  rid  of  his 
cough  before  being  operated  on,  but  he  was  anxious  to 
get  the  matter  over,  and  thought  his  cough  would  not 


68 


FISTULA  IN  CONJUNCTION  WITH  PHTHISIS 


trouble  him.  However,  although  the  fistula  was  a 
simple  one,  I could  not  get  it  to  heal  until  his  cough 
was  cured,  and  he  was  four  weeks  in  town,  whereas, 
under  favorable  circumstances,  fourteen  days  would 
have  been  ample  time  to  have  effected  the  cure. 

Prom  this  arises  a maxim  I always  adhere  to  : — 
never,  if  you  can  possibly  help  it,  operate  upon  a 
phthisical  patient  when  the  cough  is  constant ; and 
never  operate  in  unfavorable  weather.  If  your  patient 
is  in  good  circumstances  send  him  to  Brighton  or 
Hastings  or  some  other  salubrious,  genial  place, 
and  perform  the  operation  there.  You  will  find  he 
will  get  well  in  less  time,  and  possibly  save  you 
anxiety. 

Assuming,  as  I think  we  safely  may,  that  many 
patients,  the  subjects  of  fistula,  have  also  a tendency 
or  predisposition  to  phthisis,  it  will  not  be  unprofitable 
to  consider  for  a moment  why  this  should  be  the  case. 
The  conjunction  has  been  ascribed  to  tuberculous 
ulceration  of  the  bowel,  and,  no  doubt,  in  some  cases 
this  opinion  is  correct.  I am  quite  sure  now  that 
many  cases  of  incurable  ulceration  in  the  rectum  are 
tubercular,  this  portion  of  the  bowel  when  examined 
after  death  presenting  precisely  similar  conditions  to 
those  which  are  found  in  other  parts  of  the  intestine 
well  known  to  be  thus  affected.  The  ulcers  are  deep, 
and  spread  at  the  edges,  joining  others,  and  under- 
mining the  mucous  membrane,  leaving  broad  or  narrow 
bridges.  In  this  form  of  ulceration,  as  a rule,  pulmo- 
nary phthisis  does  not  co-exist,  or,  at  all  events,  only 
shows  itself  very  late  in  the  disease.  In  the  case  of  a 
young  gentleman  I saw  several  times  with  Sir  James 
Paget  and  Sir  William  Gull,  the  ulceration  was  very 


FISTULA  IN  CONJUNCTION  WITH  PHTHISIS 


69 


marked,  and  extended  high  up  the  rectum,  but  no 
chest  affection  became  apparent  until  three  years  had 
elapsed  from  the  commencement  of  the  bowel  disease. 
In  the  many  cases  of  phthisis  I have  seen  in  which 
fistula  formed,  there  has  been  no  diffused  ulceration 
of  the  rectum,  possibly  because  the  disease  spent 
itself  mainly  upon  the  lungs ; and  in  the  case  of 
tuberculous  ulceration  of  the  rectum,  anal  fistulae  are 
not  common. 

The  rule  in  my  opinion  is,  that  fistula  in  patients 
who  have  a predisposition  to  pulmonary  consumption 
commences  by  a breaking  down  of  the  connective 
tissue  beneath  the  mucous  membrane  of  the  rectum ; 
thus  a small  abscess  is  formed,  and  this  makes  its  way 
into  the  bowel  very  rapidly,  leaving  a large  patulous 
aperture.  Therefore,  I think  we  may  safely  say  that 
the  same  condition  of  health  or  constitution  which 
renders  a patient  liable  to  pulmonary  affections  gene- 
rally, renders  him  also  prone  to  fistula.  These  people 
are  usually  thin  and  ill-nourished,  and  have  very  little 
power  of  resistance  against  injurious  influences ; in- 
flammation, which  in  robust  individuals  would  result 
only  in  the  effusion  of  plastic  material,  in  them  termi- 
nates in  the  production  of  numerous  and  very  perish- 
able cells,  which  readily  form  themselves  into  purulent 
collections,  especially  in  lax  tissues.  Probably,  I 
should  say,  the  want  of  fat  in  the  ischio-rectal  fossa 
and  its  neighbourhood  disposes  to  the  formation  of  an 
abscess  there.  The  veins  have  to  sustain  a consider- 
able column  of  blood,  and  they  are  moreover  exceed- 
ingly ill  supported,  so  that  local  congestions  and 
feebleness  of  circulation  must  be  a common  condition. 
I am  inclined  to  think  that  these  general  causes  are 


70 


FISTULA  IN  CONJUNCTION  WITH  PHTHISIS 


usually  sufficient  to  explain  the  phenomena  without 
any  reference  to  tuberculous  depositions. 

Fistulse  in  persons  of  a phthisical  tendency  are 
marked  by  certain  peculiarities  which  I think  impor- 
tant to  notice.  Some  have  been  already  casually  men- 
tioned, but  I will  here  state  them  clearly. 

They  have  a disposition  to  undermine  the  skin  and 
mucous  membrane  with  remarkable  rapidity,  but  not 
to  burrow  deeply. 

The  internal  aperture  is  almost*  always  large  and 
open — on  passing  your  finger  into  the  bowel  you  can 
feel  it  most  distinctly,  often  the  size  of  a three-penny 
piece. 

The  external  opening  is  also  frequently  large  and 
ragged,  not  round ; it  is  irregular  in  form,  and  sur- 
rounded by  livid  flaps  of  skin ; when  you  pass  your 
probe  into  this  aperture  you  can  sweep  it  round  over 
an  area  of  more  than  an  inch,  and  not  infrequently  the 
skin  is  so  thin  that  you  can  see  the  probe  beneath. 

This  is  a very  different  condition  from  that  of  the 
external  orifice  of  a fistula  in  a healthy  person,  which 
is  usually  small  and  pouting , and  the  skin  is  not  de- 
tached to  any  extent  from  the  underlying  structures. 

The  discharge  is  thin,  watery,  and  curdy,  very  rarely 
really  purulent. 

The  sphincter  muscles  are  almost  invariably  very 
weak . When  you  introduce  the  finger  into  the  bowel 
you  are  hardly  sensible  of  any  resistance  being  offered. 
I think  this  a most  important  indication  of  constitu- 
tional weakness,  and  from  it  I derive  this  practical 
lesson  : — When  operating  upon  a patient  with  phthisical 
proclivity  interfere  as  little  as  possible  with  the  sphincter 
muscles , especially  the  internal.  If  you  divide  the 


ETSTTJLA  IN  CONJUNCTION  WITH  PHTHISIS  71 

sphincter,  much  incontinence  of  faeces  will  almost  cer- 
tainly result. 

It  is  common  to  observe  in  these  patients  much 
longish,  soft,  silky-looking  hair  around  the  anus. 

With  any  of  these  peculiarities  strongly  marked,  I 
am  always  suspicious  of  my  patient’s  strength;  with  all 
of  them,  or  several  of  them  present,  I feel  certain  of  his 
condition  and  act  accordingly. 

I should  say  from  my  experience,  if  you  have  a 
phthisical  patient  suffering  from  a fistula  which  gives 
him  much  pain  or  inconvenience,  by  taking  certain 
precautions  you  may  relieve  him  of  it  without  running 
any  risk  of  damaging  him.  When  a case  of  this  kind 
comes  to  me,  I am  never  in  a hurry  to  operate.  I like 
to  watch  the  patient  for  a little  while  and  observe 
whether  the  lung  disease  is  advancing,  and  also  to  find 
out  if  the  cough  is  constant ; often  these  patients  will 
assert  that  they  cough  very  little,  when  their  friends 
notice  that  they  do  so  almost  perpetually.  Wait,  if  you 
can,  for  genial  weather,  when  your  patient  need  not  be 
confined  to  a close  room.  As  to  the  operation,  I have 
already  said  that  although  it  must  be  thorough , you 
should  interfere  with  the  sphincter  as  little  as  you  can, 
and  fortunately  it  is  not  usually  necessary,  to  cut  deeply 
as  the  sinuses  are  mostly  superficial.  After  the  opera- 
tion let  the  patient  have  good  diet ; by  all  means,  plenty 
of  cream  and  milk;  if  he  can  take  it,  he  may  have  a little 
cod-liver  oil  and  steel  and  quinine,  separate  or  com- 
bined; do  not  confine  him  to  bed;  let  him  lie  on  a 
mattress ; if  you  can  manage  it  let  the  bed-room  face 
south  or  west,  and  get  plenty  of  fresh  air  into  the 
room,  the  patient  lying  well  covered  up  on  a couch  by 
the  open  window  for  hours,  in  fact,  nearly  all  day. 


72 


FISTULA  IN  CONJUNCTION  WITH  PHTHISIS 


Do  all  you  can  to  keep  him  amused  and  cheerful;  avoid 
poulticing  the  wound ; disturb  it  as  little  as  possible, 
keep  it  clean  by  gently  syringing  with  a solution  of 
carbolic  acid  (1  in  50)  night  and  morning,  and  well 
dry  afterwards  ; dress  with  wool ; ointments  as  a rule 
do  not  suit,  but  astringents  are  useful ; the  compound 
tincture  of  benzoin  agrees  very  well  with  these  wounds. 
Do  not  be  in  a hurry  to  get  the  bowels  open,  and 
manage  this  rather  by  diet  and  laxatives  than  a purge; 
if  you  set  up  a diarrhoea  in  these  patients  it  will  give 
you  trouble  and  delay  the  healing  of  the  wound. 
Unless  there  is  furring  of  the  tongue,  headache,  or 
loss  of  appetite,  I do  not  think  the  bowels  need  be 
relieved  more  than  once  in  three  or  four  days.  All 
these  matters  may  appear  so  trivial  as  to  be  almost 
unworthy  of  mention,  but  I am  sure  that  attention  to 
apparent  trifles  will  make  just  the  difference  between 
success  and  failure  with  the  patients  about  whom  I 
have  been  writing. 


CHAPTER  VII 

HEMORRHOIDS 

Almost  from  time  immemorial  haemorrhoids  have 
been  divided  into  two  varieties,  viz.  the  external  and 
the  internal,  often  also  popularly  called  blind  piles 
and  bleeding  piles,  and  this  classification  is  founded 
upon  a true  pathological  distinction ; for,  although  it 
may  be  correctly  said  that  external  piles  may  and  do 
encroach  upon  the  mucous  membrane,  and  so  are  par- 
tially internal,  and  further  that  internal  piles,  by  reason 
of  frequent  prolapse,  become  more  or  less  external, 
yet  in  the  majority  of  cases  the  difference  is  well- 
marked,  and  precludes  the  slightest  doubt  as  to  the 
diagnosis. 

In  the  external  form  the  observer  will  perceive  that 
they  are  either  the  true  hypertrophies  of  skin,  exagge- 
rations of  the  natural  rugose  state  of  the  anus,  or 
rounded  and  elongated  venous-looking  tumours  which 
pass  up  into  the  bowel. 

In  the  internal  kind  he  will  observe  that  they  are 
tumours  originating  within  the  anus,  but  which  have 
been  forced  down  outside,  and  even  may  have  put  on 
a pseudo-cutaneous  appearance  from  exposure ; having 
been,  for  more  or  less  time,  subjected  to  the  same 
conditions  as  the  skin.  In  addition  to  this,  he  will 


74 


EXTERNAL  HEMORRHOIDS 


notice  there  are  also  in  very  many  cases  cutaneous 
excrescences  accompanying  the  internal  piles.  Should 
the  surgeon  still  have  any  doubt  as  to  the  kind  of 
hsemorrlioid  he  has  to  deal  with,  let  him  return  all  the 
protruded  part  that  he  can  within  the  sphincter  ani 
by  gentle  pressure — at  the  same  time  directing  the 
patient  to  retract  or  draw  up  the  lower  part  of  the 
gut.  He  will  then  find  out  what  is  redundant  skin 
and  what  is  internal  haemorrhoid  and  prolapsed  mucous 
membrane  of  the  anus ; should  the  whole  mass  be 
irreducible  it  must  be  treated  as  a case  of  internal 
haemorrhoids.  I have  been  ratlier  particular  in  these 
introductory  observations,  because  I have  so  often 
seen  considerable  doubt  in  the  minds  of  practitioners 
as  to  the  character  of  the  affection  they  had  to  combat, 
and  a correct  conclusion  is  all-important,  especially  if 
any  operative  procedure  be  meditated. 


External  Hemorrhoids 

These  affections  are  so  prevalent  that  very  few 
persons,  either  male  or  female,  arrive  at  middle  age 
without  having  in  some  degree  suffered  from  them. 
They  occur  almost  equally  in  the  robust  and  the 
weakly,  in  the  rich  and  the  poor,  in  the  active  and 
sedentary.  JSTo  doubt  some  occupations  and  modes  of 
life  conduce  to  the  production  of  external  haemorrhoids 
more  than  others ; still,  I repeat,  there  is  no  class  of 
society  or  state  of  constitution  which  can  be  said  to  be 
entirely  exempt.  The  skin  around  the  anus  and  the 
mucous  membrane  at  the  verge  of  that  aperture  are 
remarkably  delicate  in  structure,  they  are  also  pro- 


EXTERNAL  HEMORRHOIDS 


75 


fusely  supplied  with,  nerves  and  small  vessels ; from 
these  facts  it  arises  that  anything  tending  to  irritate 
that  region  may  readily  cause  congestion  and  inflam- 
mation of  the  part,  and  result  in  an  attack  of  piles. 
To  certain  anatomical  peculiarities  of  structure  in  the 
rectum  and  its  veins,  supposed  to  be  the  predisposing 
and  also  the  active  cause  of  haemorrhoids,  I shall  refer 
further  on.  Again,  obstructions  of  the  liver  or  portal 
system,  faecal  accumulations,  or  anything  rendering 
the  return  of  blood  from  the  rectum  difficult,  are  likely 
to  conduce  to  the  same  end.  From  this  we  can  readily 
imagine  that  a great  variety  of  causes  may  bring  on  an 
attack  of  piles ; the  following  may  be  mentioned  : — 
Constipation,  often  associated  with  chronic  spasm  of 
the  external  sphincter  muscle,  diarrhoea,  too  good 
living — especially  the  consumption  of  large  quantities 
of  meat — very  coarse  fare,  indulgence  in  alcoholic 
drinks,  excessive  smoking,  violent  and  prolonged  exer- 
tion, sedentary  occupation,  exposure  to  wet  or  cold, 
discharges  from  the  bowel  resulting  from  internal  dis- 
eases, the  pressure  caused  by  the  uterus  during  preg- 
nancy, uterine  displacement,  friction  from  clothing, 
and  the  use  of  printed  paper  as  a detergent — especially 
the  cheap  papers  from  which  the  ink  comes  off  on  the 
slightest  friction — the  neglect  of  proper  ablutions  (this 
is  very  important ; many  persons  seem  to  forget  that 
the  anus  requires  quite  as  much  washing  as  any  other 
part  of  the  body),  straining,  however  induced;  all 
these  are  among  the  common  causes,  predisposing  or 
exciting,  of  external  haemorrhoids. 

I have  already  said  that  two  varieties  of  external 
piles  may  be  recognised ; the  first  ought  to  be  called 
hypertrophies  or  excrescences  of  the  skin;  the  second, 


76 


EXTERNAL  HAEMORRHOIDS 


sanguineous  venous  tumours.  When  you  look  at  either 
of  these  in  an  uninflamed  state,  you  would  think  them 
harmless  enough ; in  the  one  case  you  would  observe 
around  the  anal  orifice  merely  a certain  redundancy  of 
the  skin  forming  little  flaps  or  tabs  more  or  less  pen- 
dulous, in  addition  to  the  small  radiating  corrugations 
seen  in  the  normal  state ; in  the  other  case  you  per- 
ceive blue  veins,  rather  raised  above  the  surface,  and 
running  up  into  the  bowel,  resembling,  indeed,  varicose 
veins.  Now  these  conditions,  so  innocent  in  their 
appearance,  are  prone,  at  a very  trifling  provocation, 
to  take  on  active  inflammation,  and  to  cause  the 
patient  an  amount  of  suffering  quite  disproportionate 
to  the  pathological  appearances. 

Let  us  look  at  them  when  inflammation,  set  up  by 
any  of  the  causes  we  have  mentioned,  has  set  in. 
These  small  tabs  of  skin  are  much  increased  in  size ; 
they  may  be  very  swollen,  oedematous,  and  shiny;  they 
are  exceedingly  painful  to  the  touch ; sometimes  they 
ulcerate,  or  suppuration  may  take  place  if  the  inflam- 
mation runs  very  high,  and  hence  small  but  painful 
little  fistulas  arise.  At  times  the  oedema  is  so  consider- 
able, as  to  extend  into  the  bowel,  and  form  a large 
swollen  ring  of  skin  and  everted  mucous  membrane  all 
round  the  anus. 

So  with  regard  to  the  sanguineous  venous  haemor- 
rhoids, they  are  swollen  into  ovoid  or  globular  bluish 
tumours,  very  hard,  and  exquisitely  painful ; they  can 
be  pinched  up  between  the  finger  and  thumb  from  the 
tissues  beneath,  and  they  feel  as  if  a foreign  body  were 
present  there.  Sometimes,  but  rarely,  they  can  by 
gentle  pressure  be  emptied  of  their  contents ; but  this 
proceeding  is  not  followed  by  any  benefit  to  the 


EXTERNAL  HAEMORRHOIDS 


77 


patient,  as  in  a few  hours  they  become  more  painful 
and  larger  than  before.  These  tumours  may  be  single, 
or  two  or  three  may  be  present  at  the  same  time ; by 
irritation  they  set  up  spasm  of  the  sphincter  and  leva- 
tor-ani  muscles,  so  that  they  are  drawn  up  and  pinched, 
thus  adding  much  to  the  patient’s  suffering.  Just  as 
he  is  falling  to  sleep  a spasm  takes  place,  and  wakes 
him  up — in  addition  there  is  a constant  throbbing,  and 
the  sensation  as  if  a foreign  body  were  thrust  into  the 
anus ; this  excites  the  desire  every  now  and  again  to 
attempt  to  expel  it  by  straining,  which,  if  indulged  in, 
of  course  aggravates  the  pain.  Often  the  patient  cannot 
sit  down,  save  in  a constrained  attitude,  nor  can  he 
walk,  and  when  he  coughs  the  succussion  causes  acute 
suffering.  When  the  bowels  act,  and  for  some  hours 
afterwards,  the  distress  is  greatly  increased,  and  the 
patient,  if  not  absolutely  confined  to  bed,  is  quite 
incapable  of  attending  to  his  business.  Accompanying 
all  this  there  is  general  feverishness,  furred  tongue, 
and  usually  constipation.  Such,  then,  are  the  sym- 
ptoms of  an  acute  attack  of  external  piles,  and  if  not  a 
serious  matter,  it  is  one  causing  great  worry  and  loss 
of  time,  an  important  point  in  these  hard-working  days. 
Moreover,  one  invasion  predisposes  to  another.  I have 
known  many  patients  who  periodically  suffer  what  I 
have  described. 

There  is  a difference  of  opinion  as  to  the  mode  of 
formation  of  these  venous  tumours ; some  consider 
them  to  be  coagulations  of  blood  in  varicose  veins, 
others  as  extravasations  into  the  connective  tissue.  It 
is  possible  that  both  these  views  are  correct.  I am 
certain  that  I have  often  found  clots  contained  in  a 
distinct  sac,  formed  of  inflamed  and  condensed  areolar 


78 


EXTERNAL  HAEMORRHOIDS 


tissue,  without  any  communication  with  a vein  that  the 
most  careful  examination  could  detect ; and,  on  the 
other  hand,  I have  in  some  cases  been  able  to  squeeze 
the  blood  out  of  the  tumours  into  the  vein.  It  may  be, 
that  in  the  early  stage  of  the  disease,  the  pile  is  simply 
a varicosity  of  the  vein,  but  soon  inflammation  shuts 
the  clot  off  from  the  trunk ; and  after  a time,  and 
repeated  inflammations,  the  clot  becomes  enclosed  in  a 
sac ; but,  after  all,  the  question  to  my  mind  does  not 
seem  a very  important  one,  as  it  in  no  way  influences 
the  treatment  to  be  adopted. 

It  is  very  desirable  to  notice  the  earliest,  or  rather 
the  premonitory,  symptoms  of  one  of  these  attacks,  as 
by  this  knowledge  it  may  possibly  be  warded  off,  or  at 
all  events  much  mitigated.  Not  infrequently  a little 
extra  eating  and  drinking,  without  any  absolute  excess, 
is  the  exciting  cause;  an  indulgence  in  effervescing 
wines  or  full-bodied  ports  or  new  spirits,  being  espe- 
cially dangerous.  The  earliest  symptom  is  a sensation 
of  fulness  or  plugging  up,  and  slight  pulsation  in  the 
anus  : there  is  also  a tendency  to  constipation,  inducing 
a little  straining ; this  is  frequently  followed  by  itching 
of  a very  annoying  character,  coming  on  when  the 
patient  gets  warm  in  bed,  keeping  him  awake  for  some 
time,  and  inducing  him  to  scratch  the  part.  In  the 
morning  he  finds  the  anus  a little  swollen  and  tender, 
and  if  he  be  an  observant  person  with  regard  to  him- 
self, he  will  notice  after  a motion  a slight  stain  of 
blood.  Now  all  this  may  pass  off  with  the  simplest 
care,  and  the  slightest  medication ; but  if  the  patient 
neglect  himself,  it  will  surely  be  the  precursor  of  a 
more  or  less  severe  attack. 

The  treatment  in  such  a case,  should  be  abstinence 


EXTERNAL  HEMORRHOIDS 


79 


from  active  exercise,  rather  spare  diet,  well-cooked 
vegetables  and  fish,  not  much  meat,  no  beer  or  spirits, 
and  wine  is  not  desirable ; if  the  patient  must  take  some 
stimulant,  a glass  of  light  claret,  with  Seltzer  or  Vichy 
or  Vais  water,  will  be  the  best  beverage.  If  he  is  a 
smoker,  he  must  cut  down  his  usual  allowance  ; smok- 
ing often  causes  a sympathetic  irritation  of  the  throat 
and  rectum.  He  may  take  a warm  bath  or  a Turkish 
bath,  and  should  wash  the  anus  night  and  morning 
with  warm  water  and  Castile  soap ; after  this,  apply 
some  glycerine  and  tannic  acid,  or  some  calomel  oint- 
ment, or  a lotion  composed  of  one  teaspoonful  of  the 
Liq.  Plumbi  Subacetatis,  added  to  a wineglass  of  fresh 
milk,  which  is  very  soothing.  As  to  medicines,  he  may 
take  a Plummer’s  pill,  with  a little  taraxacum  and 
belladonna,  for  two  or  three  nights  at  bedtime ; and  in 
the  morning,  fasting,  some  effervescing  citrate  of  mag- 
nesia, or  this  draught,  which  I have  found  very  useful  on 
many  occasions: — ft  Liq. Magnes.  Carb.,  gss;  Potassae 
Bicarb.,  3j ; Syrup,  or  Tinct,  Sennse,  3ij ; Spt.  HMier. 
Nit.,  3SS ; Aquae  purae  ad  gij.  One  third  of  a tumbler 
of  Friedrichshall  water  taken  fasting,  with  twice  as 
much  warm  water,  or  Carlsbad  salts,  will  also  have  a 
good  effect. 

If  the  case  be  neglected,  and  advice  is  not  sought 
until  active  inflammation  has  set  in,  and  the  symptoms 
I have  described  are  in  full  force,  you  will  save  your 
patient  much  time,  pain,  and  after-trouble  by  snipping 
off  the  inflamed  cutaneous  excrescences,  or  in  the  case 
of  the  sanguineous  tumours,  by  laying  them  freely  open. 
The  tabs  of  skin  may  be  frozen  by  the  etherizer,  seized 
with  a pair  of  toothed  forceps,  and  quickly  snipped  off 
with  a pair  of  strong  scissors,  the  pain  soon  ceases  and 


80 


EXTERNAL  HAEMORRHOIDS 


the  wounds  heal  readily  under  any  simple  dressing. 
Care  must  be  taken  not  to  recklessly  cut  away  too  much 
skin,  or  contraction  will  follow  ; you  must  therefore  not 
make  quite  a clean  sweep  of  it,  but  take  off  a portion 
only ; that  which  is  left  will  contract  in  the  process  of 
healing.  The  best  method  of  opening  the  venous 
swellings  is  as  follows  : — Pinch  up  the  tumour  gently 
between  the  finger  and  thumb  of  the  left  hand,  transfix 
its  base  with  a curved  bistoury,  and  cut  out ; at  the 
same  moment  by  pressure  with  the  finger  and  thumb 
the  clot  may  be  extruded ; place  a piece  of  fine  cotton 
wool  at  the  bottom  of  the  sac,  and  the  operation  is 
completed;  the  pain  soon  subsides,  and  the  patient 
makes  a speedy  convalescence.  The  incision  should 
be  made  in  the  direction  of  the  radiating  folds  of  the 
anus,  in  order  to  facilitate  the  contraction  of  the  skin. 
If  these  sanguineous  tumours  are  not  interfered  with, 
the  blood  in  them  will  in  time  become  absorbed,  and 
they  may  ultimately  form  the  cutaneous  flaps  already 
described.  It  is  always  well  in  these  cases  to  ascertain, 
by  means  of  an  injection,  whether  there  be  any  internal 
piles  associated  with  the  external ; if  so  they  must  be 
attended  to,  or  the  patient  will  probably  be  made  worse 
by  any  operation  on  the  external  haemorrhoids. 

If  the  patient  will  not  submit  to  the  operative  treat- 
ment I have  recommended,  the  swollen  parts  should 
be  well  smeared  with  extract  of  belladonna  and  extract 
of  opium,  equal  parts,  and  a warm  poultice  applied. 
This  in  many  cases  gives  very  speedy  relief,  and,  as  a 
rule,  is  much  more  efficacious  than  cold  applications. 
But  sometimes  it  happens  that  cold  is  found  by  the 
patient  to  be  more  soothing ; in  that  case  a lotion  of 
Goulard  water,  with  extract  of  opium  and  belladonna, 


EXTERNAL  HEMORRHOIDS 


81 


is  useful,  or  ice  may  be  pretty  constantly  applied.  It 
does  not  answer  to  freeze  the  piles  with  the  ether- 
spray  as  I have  seen  recommended,  for  as  soon  as  the 
cold  goes  off  the  pain  is  worse  than  ever.  I have  never 
seen  much  benefit  derived  from  leeching.  Some  sur- 
geons have  insisted  that  the  inflammation  should  be 
reduced  before  removing  the  piles  by  excision.  I do 
not  think  there  is  any  need  for  this  delay ; certainly 
the  parts  are  very  tender  and  sensitive,  but  the  pain 
can  be  overcome  by  thorough  freezing,  and  I am  con- 
vinced that  convalescence  is  much  hastened  by  the 
removal  of  the  inflamed  and  oedematous  tissues,  and, 
as  far  as  my  experience  goes,  no  danger  of  any  kind 
need  be  apprehended  from  the  operation  if  it  be  pro- 
perly performed.  I much  too  often  see  these  cases 
treated  by  drastic  purges  and  gall-ointment ; this,  I am 
bound  to  say,  is  not  good  practice  ; in  the  active  stage 
it  is  harmful  to  the  patient. 

I have  said  that  one  attack  of  external  haemorrhoids 
predisposes  to  another ; it  is,  therefore,  very  advisable 
for  the  patient  so  to  live  as,  if  possible,  to  ward  off  this 
repetition.  Generally  he  should  eat  sparingly ; and  fish, 
fresh  well-cooked  vegetables,  and  ripe  fruit  should  form 
a considerable  part  of  his  diet ; he  should  avoid  spirits 
and  beer,  and  take  as  little  stimulant  of  any  kind  as 
possible;  strong  coffee  and  highly  seasoned  dishes 
must  be  abstained  from ; he  should  not  smoke,  or  only 
very  moderately  indeed;  he  should  take  plenty  of 
walking  exercise,  but  it  should  not  be  violent  nor  con- 
tinued to  overfatigue ; he  should  sleep  on  a mattress 
and  never  omit  to  wash  the  affected  part  night  and 
morning  with  cold  water ; lastly,  he  should  keep  his 
bowels  acting  daily.  If  this  latter  object  cannot  be 


82 


EXTERNAL  HAEMORRHOIDS 


accomplished  without  some  medicinal  aid,  he  will  find 
equal  parts  of  the  confections  of  black  pepper,  sulphur, 
and  senna,  a capital  remedy ; of  this  one  or  two  tea- 
spoonfuls may  be  taken  every  morning ; or  night  and 
morning  if  required.  I have  had  great  experience  in 
the  use  of  the  waters  of  Friedrich  shall  and  Carlsbad  in 
these  cases,  and  I think  them  very  beneficial,  particu- 
larly in  persons  who  are  prone  to  congestion  of  the 
liver.  Another  remedy  I find  admirable,  i.e.  a tea- 
spoonful of  the  compound  liquorice  powder  of  the 
German  pharmacopoeia,  taken  in  a wineglass  of  water, 
twice  or  thrice  in  the  week  at  bedtime.  A steady  per- 
severance in  the  line  of  treatment  I have  suggested 
will,  in  all  probability,  eradicate  the  hsemorrhoidal 
tendency. 


CHAPTER  VIII 

INTERNAL  HEMORRHOIDS 

All  those  causes  I have  mentioned  as  likely  to  induce 
external  piles  tend  also  to  the  production  of  internal 
haemorrhoids,  hut  in  addition  we  may  name  hereditary 
influence,  diseases  of  the  genito-urinary  system,  and  the 
state  of  recovery  from  childbirth. 

During  pregnancy  external  venous  haemorrhoids  are 
frequent,  and  these  may,  and  often  do,  pass  away  after 
labour,  in  common  with  varicosities  of  the  legs  and 
labia  vaginae ; but  the  reverse  is  the  case  with  regard 
to  internal  haemorrhoids  : these  most  frequently  make 
their  appearance  after  parturition,  when  all  the  parts 
are  relaxed  and  uterine  involution  is  going  on.  I will 
not  attempt  to  give  any  reason  for  this  peculiarity ; I 
only  state  a fact  I have  repeatedly  observed. 

Our  French  confreres  for  long  past  have  not  been 
at  all  satisfied  with  the  usually  accepted  explanation 
of  the  etiology  of  piles,  either  external  or  internal. 
They  do  not  consider  that  any  causes  which  are 
occasional  can  induce  such  an  afflux  and  stasis  of 
blood  in  the  rectal  veins  as  shall  be  productive  of 
haemorrhoids. 

Neither,  say  they,  sedentary  occupation,  excesses 
at  the  table,  venereal  abuses,  passive  pederasty,  the 


84 


INTERNAL  HAEMORRHOIDS 


immoderate  and  prolonged  use  of  enemata,  drastic 
purgatives,  nor  habitual  and  severe  constipation,  can 
one  or  all  initiate  true  haemorrhoids,  They  therefore 
with  praiseworthy  diligence  sought  for  the  true  pre- 
disposing cause  in  the  anatomy  and  physiology  of  the 
rectum;  and  Professor  Yernenil,  the  distinguished 
Parisian  surgeon,  says  he  has  discovered  that  cause  in 
the  peculiar  distribution  of  the  veins  and  the  course 
they  take  in  the  coats  of  the  rectum  a few  inches 
above  the  anus.  The  preparations  and  dissections  M. 
Yerneuil  made  to  illustrate  and  prove  his  views  are 
now  in  the  Dupuytren  Museum  at  Paris ; and  the  cor- 
rectness of  the  anatomy,  and  the  deductions  made 
from  it,  have,  say  recent  French  authors,  not  only 
been  supported,  but  even  proved,  by  the  dissections  of 
Gosselin  in  1864,  Dubrueil  and  Richard  in  1868,  and 
lastly  by  Duret  in  1877. 

I shall  endeavour,  as  briefly  and  clearly  as  I possibly 
can,  to  place  before  my  readers  the  anatomy  as  stated 
by  M.  Yerneuil,  because  it  is  considered  to  give  the 
reasons  for  a method  of  treating  haemorrhoids  strongly 
advocated  in  France,  but,  as  far  as  I know,  little  prac- 
tised in  England: — 1st.  Professor  Yerneuil  considers 
that  the  superior  haemorrhoidal  veins  only  are  con- 
nected with  the  portal  system  and  solely  form  internal 
haemorrhoids ; external  piles  being  formed  from  the 
inferior  and  middle  haemorrhoidal,  which  are  con- 
nected with  the  general  venous  system,  and  do  not,  or 
only  in  the  most  remote  degree,  form  connections  with 
the  superior  haemorrhoidal  veins,  and  thus  the  two 
venous  systems,  portal  and  general,  are  practically 
distinct. 

2nd.  That  the  superior  haemorrhoidal  veins  com- 


INTERNAL  HAEMORRHOIDS 


85 


mence  at  the  upper  border  of  the  external  sphincter, 
and  lie  under  the  mucous  membrane  of  the  rectum. 
At  a definite  height  of  about  4 inches  (10  or  11  centi- 
metres) they  perforate  abruptly  the  muscular  coats  of 
the  bowel,  and  unite  to  form  the  five  or  six  large  veins 
found  in  the  meso -rectum ; these  then  join  the  inferior 
mesenteric  veins,  which  pass  into  the  splenic  and  portal 
veins,  and  thus  enter  the  liver. 

3rd.  Where  the  superior  haemorrhoidal  veins  per- 
forate the  wall  of  the  rectum,  Yerneuil  claims  to  have 
discovered  that  they  pass  through  “ veritables  bouton- 
nieres musculaires,”  which  muscular  button-holes,  not 
being  surrounded  by  any  protective  fibroid  tissue,  have 
the  power  of  contracting  and  causing  such  stasis  and 
congestion  in  the  superior  haemorrhoidal  veins  as  to 
constitute  the  46  primum  mobile”  in  the  formation  of 
internal  piles.  Dubrueil  further  calls  attention  to  the 
fact,  that  the  muscular  button-holes  are  double  and  at 
right  angles  to  each  other,  the  first  set  being  formed 
by  the  circular  fibres,  and  the  second  by  the  longi- 
tudinal fibres  of  the  rectum.  These  contractile  button- 
holes constitute,  says  Yerneuil,  not  only  the  passive, 
but  also  the  active  cause  of  haemorrhoids ; any  intes- 
tinal irritation  will  produce  violent  and  spasmodic 
contractions  of  the  muscular  apertures,  and  these  con- 
tractions are  communicated  to  the  levator  and  sphincter 
ani  muscles,  and  a rapid  development  of  internal 
haemorrhoids  will  take  place.  Commonly,  in  addition, 
those  occasional  causes  (formerly  considered  as  primary 
causes)  come  into  play,  and  the  small  varicosities 
found  at  the  lower  border  of  the  internal  sphincter 
(and  present  even  in  infants,  say  the  French)  soon 
become  fully  formed  piles.  The  practical  outcome, 


86 


INTERNAL  HEMORRHOIDS 


from  the  above  anatomy  and  physiology  by  the  French 
authors,  is  very  important,  viz.  that  for  the  cure  of  the 
great  majority  of  internal  haemorrhoids,  nothing  is 
required  but  the  gentle  and  thorough  dilatation  of  the 
external  and  internal  sphincter  muscles ; no  ligature, 
no  cautery,  with  or  without  clamp,  is  wanted,  and  no 
immediate  removal  of  the  piles  need  take  place. 
The  anatomy  of  the  rectum,  given  by  M.  Yerneuil,  has 
been  known  for  many  years,  but  only  recently  (in 
1874)  has  the  practice  of  dilatation  been  recommended 
for  the  cure  of  hgemorrhoids  by  that  gentleman ; and 
it  appears  to  me  that  the  discovery  of  that  treatment 
was  the  result  rather  of  accident  than  of  reflection  and 
deduction  from  any  known  anatomy  or  physiology. 
The  case  which  opened  the  eyes  of  Professor  Yerneuil 
to  the  advantages  of  dilatation  is  thus  related  by  him : 
— “ I was  consulted  by  a distinguished  gentleman  who 
had  for  fourteen  years  suffered  from  anal  pains  sup- 
posed to  be  caused  by  fissure,  but  they  in  reality  were 
caused  by  internal  hgemorrhoids  which  had  become  pro- 
cidented  and  irreducible ; with  this  state  not  only  had 
the  patient’s  pains  been  redoubled,  but  he  suffered  such 
loss  of  blood  as  to  bring  him  near  to  death ; his  angemia 
was  so  profound  that  I considered  the  usual  operative 
methods  too  dangerous  to  be  undertaken,  and  as  the 
sphincters  were  very  contracted  I contented  myself  by 
dilating  them,  and  from  that  day  the  pain  and  loss  of 
blood  ceased,  the  piles  were  cured,  and  did  not  return.” 
“ Encouraged  by  this  happy  experiment,”  says  M. 
Yerneuil,  “ I hastened  to  put  it  into  practice  in  other 
cases  with  most  excellent  result.”  M.  Fontan  a little 
later,  not  knowing,  I presume,  of  M.  Yerneuil’s  success, 
also  accidentally  discovered  that  forcible  dilatation  of 


INTERNAL  HEMORRHOIDS 


87 


the  sphincters  cured  haemorrhoids  ; for,  says  he,  having 
dilated  the  muscles  for  the  purpose  of  curing  a fissure 
in  a patient  who  also  suffered  from  haemorrhoids  ( J une, 
1875),  I found  that  with  the  cessation  of  the  symptoms 
of  fissure,  the  haemorrhoids,  the  constipation,  the  daily 
bleeding,  and  the  prolapsus  also  disappeared,  and  I 
was  struck  by  this  unhoped-for  result.  ( Vide  i(  Fontan 
on  the  Cure  of  Haemorrhoids  by  Forcible  Dilatation,’  ’ 
Paris,  1877.) 

It  would  be  presumptuous  in  me  to  dispute  the 
anatomical  facts  set  forth  by  Professor  Verneuil  and 
endorsed  by  such  men  as  Giosselin,  Dubrueil,  Duret, 
and  others ; indeed,  the  dissections  that  I have  been 
able  to  make,  induce  me  to  concur  in  the  main  points 
set  forth  by  the  learned  professor ; but,  with  all  due 
deference,  I cannot  admit  as  a fact  the  almost  absolute 
separation  of  the  portal  and  general  venous  systems. 
I am  quite  confident  that  in  the  dissection  of  morbid 
specimens,  near  the  anus,  you  do  find  a considerable 
communication  between  the  superior,  inferior,  and 
middle  hgemorrhoidal  veins.  One  fallacy  I would 
suggest  arises  in  M.  Yerneuil’s  physiology,  from  the 
fact  of  his  having  injected  the  superior  hsemorrhoidal 
veins  from  the  portal  vein,  thus  forcing  the  injection 
in  a direction  opposed  to  the  natural  flow  of  the 
stream  of  blood.  Again,  admitting  the  existence  of 
the  “ button-hole  ” apertures  through  the  muscular 
walls  of  the  rectum,  I should  demur  to  the  deduction 
made  by  M.  Yerneuil,  that  they  cause  by  contraction 
an  obstacle  to  the  return  of  blood  from  the  lower 
portion  of  the  rectum ; and  on  the  contrary  I should 
infer,  that  these  contractile  apertures  really  play  the 
part  of  valves  to  support  the  column  of  blood  to  the 


88 


INTERNAL  HAEMORRHOIDS 


liver,  and  in  place  of  causing  stasis,  prevent  it  by 
opposing  regurgitation  in  congested  states  of  tbat 
organ.  In  tbe  second  place  I would  rather,  in  accor- 
dance with  general  physiological  principles  infer,  that 
the  contraction  of  the  circular  and  longitudinal  mus- 
cular fibres  of  the  bowel  favours,  and  does  not  retard, 
the  upward  flow  of  the  blood  ; and  I am  not  con- 
vinced, whatever  may  be  the  value  of  dilatation  of  the 
sphincters  in  treatment,  that  the  physiology  of  M. 
Yerneuil  explains  in  a wholly  satisfactory  manner  the 
causes  and  pathology  of  haemorrhoids.  One  more 
point  I would  mention.  In  Professor  Verneuil’s  thesis 
he  makes  no  allusion  to  the  part  played  by  the  arteries 
in  the  formation  of  piles ; yet  I should  think  no  one 
could  fail  to  note  that  haemorrhoids  are  not  merely 
varicosities  of  veins,  but  tumours,  into  the  structure 
of  which  considerable  arteries  enter.  When  further 
on  I discuss  the  various  methods  of  operating  on 
haemorrhoids,  I shall  give  my  views  and  experience  of 
the  treatment  by  dilatation. 

Internal  piles  present  several  varieties  in  appearance, 
structure,  size,  position,  and  other  characteristics. 

They  may  be  so  small  as  to  exhibit-little  more  than 
an  increased  number  and  size  of  capillary  vessels  with 
thickening  of  the  submucous  tissue  ; in  fact,  there  may 
be  only  a deep  red  velvety  appearance  of  the  mucous 
membrane,  readily  yielding  blood,  or  they  may  be  large 
solid  tumours  the  size  of  an  ordinary  bantam  fowl’s 
egg.  Some  haemorrhoids  are  attended  with  bleeding  of 
an  arterial  character,  others  with  venous  haemorrhage, 
while  some,  particularly  in  their  later  stages,  do  not 
bleed  at  all.  Some  lie  quietly  high  up  within  the 
internal  sphincter,  and  are  to  be  protruded  only  by 


INTERNAL  HAEMORRHOIDS 


89 


straining  after  tlie  administration  of  an  enema ; others 
always  come  down  at  stool,  and  whenever  the  patient 
makes  any  exertion,  or  stoops,  walks,  or  stands  about 
much ; again,  some  are  always  down.  This  last  sym- 
ptom is  peculiar  to  old-standing  cases.  These  various 
conditions  depend  in  great  measure  upon  the  duration 
of  the  disease  and  the  condition  of  the  sphincter  mus- 
cles as  to  strength  or  weakness ; a relaxed  condition, 
such  as  frequently  exists  in  women  and  in  men  of  lax 
fibre,  allowing  the  protrusion  of  even  small  haemor- 
rhoids on  the  slightest  exertion.  This  may  be  specially 
noticed  in  the  common  case  of  a perineal  haemorrhoid 
in  females  who  have  borne  children. 

As  a rule  patients  do  not  suffer  much  from  internal 
haemorrhoids,  unless  they  become  inflamed  or  are  con- 
stantly coming  down  and  getting  compressed  by  the 
sphincters ; hence  the  amount  of  suffering  depends  in  a 
measure  upon  the  state  of  these  muscles,  as  does  also  the 
amount  of  congestion  of  the  piles  themselves.  Inflam- 
mation is  very  soon  lighted  up  in  these  cases ; unusual 
straining  with  a costive  motion,  a drastic  purge,  sitting 
on  a damp  seat,  excessive  sexual  indulgence,  or  a little 
excess  in  alcohol  or  in  eating,  may  be  sufficient  to  start 
it.  When  the  part  is  extruded  and  gets  nipped  by  the 
sphincters,  partial  strangulation  takes  place,  and  in  some 
cases  you  see  large,  inflamed,  bluish  haemorrhoids  con- 
stricted by  a broad  band  of  everted  sphincter  muscle 
and  mucous  membrane,  and  this  constriction  may  take 
place  to  such  an  extent  as  to  occasion  more  or  less 
sphacelus.  I have  very  rarely  seen  this  occur  to  a 
degree  sufficient  to  effect  a cure  of  the  malady,  although 
it  may  afford,  temporarily,  great  relief. 

In  the  earlier  stages  of  the  complaint,  when  the  piles 


90 


INTERNAL  HEMORRHOIDS 


come  down  at  stool,  they  nearly  always  bleed,  but  they 
spontaneously  return  within  the  sphincter  after  the 
bowel  is  emptied,  or  upon  the  patient  resuming  the 
erect  posture,  or,  at  all  events,  upon  lying  down  and 
voluntarily  retracting  them ; and  then  the  bleeding 
ceases.  Later  in  the  progress  of  the  disease,  the  patient 
is  compelled  to  return  them  by  pressure,  and  then  they 
keep  up ; but  in  still  further  advanced  cases,  although 
returned,  they  will  not  remain  in  place  if  the  least 
exertion  be  made. 

As  regards  the  structure  and  appearance  of  internal 
haemorrhoids,  three  broadly-marked  kinds  may  be 
observed,  viz.  the  capillary  haemorrhoid,  the  arterial 
haemorrhoid,  and  the  venous  haemorrhoid ; at  times 
all  perfectly  distinct,  at  others  united  in  the  same 
patient. 

The  first  variety  I should  describe  as  small,  florid 
raspberry -looking  tumours,  having  a granular,  spongy 
surface,  and  bleeding  on  the  slightest  touch ; these 
piles  are  often  situated  rather  high  in  the  bowel. 
Although  they  are  so  insignificant  in  size,  the  quantity 
of  blood  lost  from  them  may  be  very  considerable,  and 
occasion  a serious  drain  upon  the  patient’s  constitu- 
tion ; I have  seen  many  persons  quite  blanched  by  the 
losses  they  sustain. 

In  structure  they  consist  almost  entirely  of  hyper- 
trophic capillary  vessels  and  spongy  connective  tissue, 
and  therefore  I think  a good  name  for  them  is  the 
“ capillary  haemorrhoid.”  They  resemble  arterial  naevi 
very  closely  indeed  in  their  microscopic  structure,  ex- 
cept that  they  are  covered  externally  by  a very  much 
thinner  membrane,  and  consequently  are  readily  made 
to  bleed.  If  these  haemorrhoids  exist  for  a consider- 


INTERNAL  HEMORRHOIDS 


91 


able  time  uninterfered  with,  or  if  powerful  astringents 
are  applied  to  them,  they  lose  their  velvety  granular 
appearance,  the  bleeding  ceases  or  diminishes  greatly, 
and  they  remain  dormant  for  a longer  or  shorter 
period ; but  in  most  cases  they  eventually  recommence 
growing,  and  assume  a smooth  shining  surface  resem- 
bling ordinary  mucous  membrane;  at  the  same  time 
the  main  vessels  feeding  the  growth  increase  in 
diameter,  and  the  areolar  tissue  becomes  thickened 
and  more  abundant ; an  exudation  of  lymph  and  fibrin- 
ous matter  takes  place  beneath  the  mucous  mem- 
brane, obliterating  the  capillaries  and  arresting  the 
bleeding  from  the  surface.  These  changes  I believe 
to  be  the  result  of  slow  processes  of  inflammation. 
I am  here  only  describing  what  I have  repeatedly 
seen,  and  I think  in  this  way  most  commonly  the 
second  variety  or  arterial  internal  hcemorrhoid  is 
formed. 

They  may  be  thus  described : — Tumours  varying  in 
size,  attaining  sometimes  very  considerable  dimensions, 
glistening  on  their  surface,  slippery  to  the  touch,  hard 
and  vascular,  if  scratched  they  bleed  freely,  the  blood 
is  bright  red  and  issues  “ per  saltum.”  If  you  pass 
your  finger  into  the  bowel  you  will  feel  entering  into 
the  upper  part  of  each  haemorrhoid  an  artery,  pulsating 
with  as  much  force  as  the  radial,  and,  in  many  cases, 
of  a calibre  but  little  less  than  it.  On  dissecting  one 
of  these  tumours  you  will  find  it  consists  of  numerous 
arteries  and  veins  freely  anastomosing,  tortuous,  and 
sometimes  dilated  into  pouches,  and  a stroma  of  cell 
growth  and  connective  tissue,  the  latter  most  abound- 
ing. These  advanced  haemorrhoids  are  certainly  not, 
as  some  have  described  them,  merely  dilated  vessels 


92 


INTERNAL  HAEMORRHOIDS 


with  a little  cellular  tissue,  or  sacs,  or  cells  with  fluid 
contents  which  can  be  emptied  by  squeezing. 

The  third  variety  is  the  venous  internal  hcemorrhoid , 
and  in  this  the  venous  system  predominates.  The 
tumours  are  often  very  large.  I have  seen  them  quite 
the  size  of  a hen’s  egg.  They  are  bluish  or  livid  in 
colour,  and  they  are  hardish ; the  surface  may  be 
smooth  and  shiny  or  pseudo-cutaneous ; they  prolapse 
very  readily,  and  are  often  constantly  down ; they  do 
not  usually  bleed  much,  but  if  pricked  the  blood  may 
be  either  venous  or  arterial.  This  form  is  commonly 
found  in  women  who  have  borne  many  children  and 
who  have  an  enlarged  or  retroverted  uterus ; they 
often  occur  about  the  change  of  life.  This  form  of 
haemorrhoid  may  be  called  “ the  passive  kind.”  They 
are  also  seen  in  men  with  enlarged  or  indurated  livers, 
in  whom  the  portal  system  is  constantly  engorged, 
and  the  circulation  through  the  abdominal  viscera  is 
obstructed.  This  is  the  form  of  haemorrhoid  spirit- 
drinkers  get.* 

I never  hesitate  to  operate  on  these  cases,  but 
I observe  certain  precautions  before  doing  so  ; if  the 
liver  is  in  fault  I prescribe  careful  living,  a course  of 


* Although  venous  haemorrhoids  are  usually  found  in  adults,  I have 
seen  them  in  children.  Here  is  a case.  Henry  S — , aet.  3,  was  brought 
to  St.  Mark’s  Hospital,  October,  1865.  He  never  was  a robust  child, 
and  looks  delicate  now.  For  eighteen  months  his  mother  has  noticed 
something  come  down  when  he  went  to  stool ; latterly  he  complained  of 
pain,  and  there  had  been  slight  bleeding.  On  examination  nothing 
abnormal  could  be  seen.  Of  course  I suspected  polypus,  and  ordered 
an  injection  to  be  given ; after  the  bowels  had  acted  I found  three 
well-marked  venous  haemorrhoids  had  come  down  outside.  There  was 
slight  ulceration  of  the  mucous  membranes  between  them.  Laxatives, 
cod-liver  oil  and  steel  wine,  together  with  the  use  of  astringent  oint- 
ments, effected  a cure. 


INTERNAL  HAEMORRHOIDS 


93 


Carlsbad  waters,  and  the  “ wet  pad”  over  the  liver, 
together  with  shampooing  and  the  cold  douche ; also 
the  chloride  of  ammonium  may  be  very  useful  (3  or 
4 grains  three  times  in  the  day).  In  women  any 
uterine  complication  should  be  attended  to,  and  in 
men  after  the  operation  it  will  not  do  to  allow  them  to 
live  freely;  for  some  little  time  the  bowels  should  be 
kept  acting  well,  and  stimulants  should  be  interdicted ; 
if  these  precautions  be  neglected  you  may  get  symptoms 
of  congestion  of  the  head,  shown  by  flushed  face  and 
tensive  throbbing  headache,  or  an  attack  of  gout  may 
supervene,  as  I have  seen  on  several  occasions.  Some- 
times haemorrhage  of  venous  character  will  take  place 
a week  or  ten  days  after  the  operation,  from  the  surface 
of  the  unhealed  wounds ; if  this  is  not  excessive  it 
should  not  be  interfered  with.  No  doubt  these  are 
the  cases  that  the  old  writers  advised  should  not  be 
operated  upon,  for  fear  of  apoplexy  or  other  internal 
disease  resulting.  My  experience  is  that  there  is 
no  danger  if  ordinary  common-sense  precautions  are 
adopted. 

I have  frequently  been  consulted  as  to  the  propriety 
of  operating  upon  haemorrhoids  in  pregnant  women. 
I think  the  operation  quite  admissible  if  the  patient  is 
losing  much  blood  or  is  suffering  greatly.  I recently 
had  a case  at  St  Mark’s  in  a woman,  five  months 
pregnant,  who  was  voiding  such  quantities  of  blood 
that  she  was  quite  blanched,  and  it  was  absolutely 
necessary  to  interfere ; she  had  no  untoward  symptoms 
after  the  ligature  of  five  piles,  nor  was  her  recovery 
much  retarded.  I have  operated  many  times,  always 
in  urgent  cases,  but  only  once  has  a miscarriage  re- 
sulted. I always  keep  these  patients  recumbent  longer 


94 


INTERNAL  HEMORRHOIDS 


than  ordinary  cases,  as  if  they  get  about  too  soon  the 
wounds  do  not  heal  well. 

It  has  often  occurred  to  me  to  point  out  the  three 
varieties  of  haemorrhoids  I have  described,  as  existing 
at  the  same  time  in  the  same  patient,  a circumstance 
which,  I think,  tends  to  confirm  the  opinion  I entertain 
that  they  are  only  modifications  of  one  initial  disorder. 
I would  by  no  means  dogmatically  affirm  that  what  I 
have  called  the  (i  arterial  haemorrhoid ’ ’ always  follows, 
or  is  preceded  by  the  capillary  form  of  haemorrhoid, 
but  I am  sure  it  is  frequently  so  ; it  has  happened  to 
me  several  times  to  see  cases  where  nitric  acid  has  been 
applied  to  capillary  piles  with  the  result  of  arresting 
the  bleeding,  and  for  months  or  longer  relieving  the 
patient,  but  the  second  variety  of  haemorrhoid  has  been 
gradually  growing,  and  fully  formed  tumours  have 
eventually  become  developed. 

Here  is  an  illustration. 

A gentleman  came  under  my  care  in  the  year  1862. 
He  had  two  very  characteristic  capillary  haemor- 
rhoids, and  lost  almost  daily  a quantity  of  blood. 
The  case  was  one  peculiarly  well  suited  for  the  nitric 
acid  treatment  which  at  that  time  was  much  practised. 
I applied  the  acid  thoroughly  without  causing  any 
severe  pain.  Tbe  result  was  highly  satisfactory,  the 
bleeding  was  at  once  stopped,  and  the  patient  left  my 
care  quite  happy. 

In  the  year  1864,  about  eighteen  months  after  I had 
first  seen  him,  he  again  consulted  me,  complaining  of 
discomfort  in  the  rectum  and  of  a protrusion  on  going 
to  stool.  He  only  very  occasionally  lost  blood;  on 
examination  after  an  injection  I found  three  haemor- 
rhoids fully  formed,  and  I advised  an  operation  by 


INTERNAL  HAEMORRHOIDS 


95 


ligature.  He,  however,  objected  to  that,  and  wished 
me  to  re-apply  the  acid  ; this  I declined  to  do,  knowing 
that  it  would  not  in  any  degree  benefit  him.  He  went 
away  to  consider  whether  he  would  have  the  opera- 
tion done,  but  he  did  not  return  again  for  nine  or 
ten  months ; he  then  told  me  that  after  seeing  me  he 
consulted  another  surgeon,  who  applied  nitric  acid 
four  times  for  him,  but  that  he  had  gained  only  very 
temporary  benefit,  and  that  he  was  now  worse  than 
ever  and  wished  for  a radical  cure.  On  examining 
him  I found  five  haemorrhoids,  three  large  and  of  the 
venous  character,  and  two  small  of  the  capillary  kind, 
which  had  formed  since  I saw  him. 

Some  years  ago  it  was  a common  thing  for  patients 
to  come  to  St.  Mark’s  Hospital  with  advanced  haemor- 
rhoids, relating  this  history  : “ Their  piles  had  been 
(as  they  called  it)  operated  upon  a year  or  so  before 
with  acid,  and  for  some  time  they  were  better,  but 
that  latterly  they  had  become  worse  than  ever,  but 
they  rarely  bleed  now,  although  before  the  acid  was 
applied  they  lost  a good  deal.” 

Although  the  three  broad  divisions  I have  described 
are  most  usually  seen,  sometimes  it  occurs  to  one  to 
find  a large  haemorrhoidal  tumour  with  a granular 
capillary  surface  which  bleeds  very  freely ; these  are 
piles  that  for  some  reason  or  other  have  formed  and 
grown  very  rapidly;  they  are  usually  situated  high 
up  the  bowel,  and  have  not  protruded,  and  have  not 
suffered  from  repeated  attacks  of  inflammation. 

In  the  velvety  or  capillary  haemorrhoid  the  patient’s 
symptoms  are  principally  such  as  arise  from  repeated 
small  losses  of  arterial  blood,  which  I have  noticed  are 
much  more  exhausting  than  venous  haemorrhages ; the 


96 


INTERNAL  HAEMORRHOIDS 


latter  often  relieve,  the  former  always  in  time  depress. 
These  piles  are  so  small  that  they  give  no  trouble  by 
their  size,  and  they  protrude  only  slightly,  if  at  all, 
on  going  to  the  closet ; moreover,  there  is  no  pain 
unless  there  be  the  complication  of  ulceration.  These 
patients  complain  of  frequent  pains  in  the  back  and 
loins,  also  in  the  male  in  the  spermatic  cord  and 
testicles ; they  have  great  lassitude,  and  not  infre- 
quently the  sexual  powers  are  interfered  with.  I have 
seen  many  cases  in  which  this  was  the  symptom  that 
induced  the  person  to  seek  advice.  One  case  par- 
ticularly is  recalled  to  my  mind  from  the  fact  that 
the  gentleman  had  paid  a large  sum  of  money  to  a 
charlatan  who  had  been  treating  him  for  impotence  the 
result  of  spermatorrhoea.  In  women  menstruation  may 
gradually  cease,  and  a condition  of  profound  anasmia 
result.  This  is  well  illustrated  by  a case  that  was  sent 
me  by  my  friend,  the  late  Dr  Chapman,  of  Biarritz. 

A young  lady,  set.  20,  formerly  robust  and  bealtby,  gradually  fell  ill ; 
sbe  became  languid,  fretful,  fanciful,  and  very  ansemic.  Menstruation 
ceased  almost  entirely ; only  once  in  three  or  four  months  bad  sbe  a 
scanty  pale  discharge.  Sbe  did  not  complain  of  any  pain  except  in  the 
back  and  legs  on  attempting  to  walk.  Sbe  bad  taken  any  quantity  of 
ferruginous  medicines,  and  bad  been  recommended  by  various  medical 
men  to  try  the  baths  at  Scbwalbacb  and  other  German  watering-places, 
the  disorder  being  supposed  to  be  uterine.  Through  delicacy  sbe  never 
mentioned  that  sbe  bad  lost  blood  per  anum,  and  sbe  bad  never  been 
directly  asked  the  question.  Fortunately  for  her  Dr  Chapman,  under 
whose  care  sbe  came,  put  it  to  her  point  blank,  when  she  admitted 
that  sbe  bled  almost  daily  when  the  bowels  acted.  The  mystery  was 
now  solved.  By  the  advice  of  Dr  Chapman  sbe  came  to  me,  and  I 
found  that  sbe  bad  three  very  vascular  capillary  haemorrhoids.  I 
removed  them — recovery  ensued  without  a bad  symptom,  and  sbe  soon 
regained  her  former  health. 

I was  consulted  two  years  ago  by  a physician  about  bis  daughter,  who 
bad  fallen  into  a very  despondent  state  of  mind,  and  was  also  weak  and 
anaemic.  Menstruation  bad  ceased  for  some  months.  Uterine  disease 


INTERNAL  HEMORRHOIDS 


97 


Lad  been  diagnosed  and  treated  without  benefit.  Latterly  sbe  bad  said 
something  was  the  matter  with  her  bowel,  and  advice  was  sought.  On 
interrogation  it  appeared  that  sbe  lost  blood  almost  daily,  and  occa- 
sionally in  large  quantities,  so  that  sbe  bad  fainted  in  the  water-closet. 
Nothing  protruded,  and  sbe  bad  no  actual  pain,  only  a burning  sensa- 
tion at  the  bottom  of  the  back. 

On  examination  I found  an  extremely  vascular  patch  of  mucous 
membrane  over  the  internal  sphincter,  about  the  size  of  a shilling.  It 
yielded  arterial  blood  at  the  slightest  touch,  and  the  sphincter  muscles 
were  somewhat  contracted.  Gentle  dilatation,  and  one  touch  with  the 
Paquelin  cautery  completely  cured  her. 

It  is  these  daily  small  losses  which  are  apt  to  be 
overlooked,  and  which  female  patients  accustomed  to 
their  monthly  flux  scarcely  think  worthy  of  mention, 
but  which,  when  added  to  menstruation,  become  a 
serious  matter,  and  speedily  induce  chlorosis  and  an 
amount  of  debility  which  can  be  combated  only  by 
removing  the  primary  cause  of  the  malady.  Yery 
tiresome  constipation  is  usually  found  attendant  upon 
this  condition,  and  often  continues  after  the  patient 
has  recovered  her  general  health.  It  is  only  to  be 
overcome  by  patient  attention  to  diet,  exercise,  and 
the  administration  of  such  medicines  as  give  tone 
and  gently  stimulate  the  colon,  without  irritating  or 
purging.  I have  found  faradisation  a valuable  adjunct 
to  other  treatment.  You  do  not  generally  find  more 
than  two  or  three  capillary  haemorrhoids  in  the  same 
patient — very  often  only  one,  and  in  women  this  is 
almost  always  situated  anteriorly,  and  then  it  is  very 
easily  prolapsed.  It  is  this  variety  of  the  disease  which 
is  benefited  by  the  application  of  fuming  nitric  acid 
— I say  benefited,  not  absolutely  cured,  for,  in  my  ex- 
perience, you  cannot  by  any  means  be  certain  of  effect- 
ing the  latter  result.  Had  the  use  of  the  acid  been 
restricted  to  this  form  of  pile,  it  would  not  have  fallen 

7 


98 


INTERNAL  HAEMORRHOIDS 


into  such  utter  disuse  as  it  has ; it  was  the  unsurgical 
attempt  to  cure  large  hard  haemorrhoids  with  it  that 
brought  it  into  discredit.  In  these  small  vascular, 
granular  piles,  strong  carbolic  acid  is  a very  good 
application,  as  also  is  the  subsulphate  of  iron  in  the 
form  of  an  ointment  (3SS  to  33  of  Unguentum  Cetacei  is 
the  strength  I employ)  or  as  a suppository  (gr.  ij  c.  gr.  v 
Cacao  butter).  It  acts  as  a most  powerful  astringent; 
it  is  not  cauterant ; it  causes  no  pain — in  fact,  in  in- 
flamed haemorrhoids  it  seems  to  act  as  a sedative ; it 
arrests  haemorrhage  with  absolute  certainty.  I have 
with  this  remedy  effected  many  cures,  and  materially 
relieved  numbers  of  cases  when  an  operation  has  not 
been  desirable,  or  when  the  patient  was  too  nervous  to 
submit  to  one.  I am  confident  now  from  a large  expe- 
rience that  it  is  a most  valuable  agent  in  the  treatment 
of  many  rectal  affections.  Rouse  and  Co.,  the  chemists 
in  Wigmore  Street,  prepared  for  me  an  excellent  Liquor 
Ferri  Subsulphatis,  and  I found  it  answer  admirably 
as  a styptic  and  astringent  in  small  ulcerations  as  well 
as  capillary  haemorrhoids. 

I may  as  well  remark  here  that  the  capillary  hae- 
morrhoid, or  the  pile  with  a capillary  surface,  is  the 
only  form  likely  to  be  benefited  by  the  application 
of  nitric  acid  or  acid  nitrate  of  mercury.  Ten  years 
ago,  when  this  treatment  was  in  vogue,  it  was  fre- 
quently used  in  the  most  reckless  and  unscientific 
manner,  quite  regardless  of  how  much  it  really  could 
do.  I used  to  see  at  the  hospital  patients  with  large, 
fully  developed  rectal  tumours,  to  which  acid  had  been 
applied  half  a dozen  or  more  times,  causing  great  pain, 
and  with  the  result  of  no  real  curative  impression 
being  made  upon  the  disease.  I am  sorry  to  say  this 


INTERNAL  HEMORRHOIDS 


99 


method  is  not  yet  quite  obsolete,  for  not  very  long  ago 
I saw  with  Dr  Playfair  an  elderly  lady  with  large  piles, 
who  had  suffered  very  severely  from  several  applications 
of  strong  acid,  made  a short  time  before  by  a hospital 
surgeon  of  considerable  repute. 

In  the  second  variety,  or  arterial  internal  haemor- 
rhoid, the  suffering  occasioned  is  more  directly  asso- 
ciated with  the  condition  of  the  haemorrhoid  itself  as  to 
inflammation  or  ulceration,  and  with  the  state  of  the 
sphincter  ani  muscles.  These  piles  protrude  at  stool 
or  on  making  some  particular  movements,  as  stooping, 
&c.,  and  in  that  way  alone  they  cause  much  discomfort ; 
they  also  discharge  a gummy  acrid  mucus,  which  keeps 
the  part  constantly  damp,  leads  to  excoriations  around 
the  anus,  and  favours  the  growth  of  cutaneous  excres- 
cences; moreover,  it  stains  the  linen,  and  on  this 
account  is  a source  of  great  annoyance  to  sensitive, 
delicate-minded  persons.  Generally  after  visiting  the 
water-closet  the  patient  is  some  time  before  he  can  get 
at  all  comfortable,  often  having  to  lie  down,  and  when 
he  walks  about  he  is  almost  always  aware  of  the  fact 
that  he  has  a rectum.  In  health  no  person  feels  that 
he  posesses  one  organ  more  than  another,  unless  he 
has  to  use  that  organ;  often  the  first  intimation  of 
impairment  of  health  is  the  recognition  of  the  fact  that 
there  is  a preponderance  of  sensitiveness  or  some 
abnormal  sensation  in  one  member  of  the  body.  So  in 
rectal  diseases  the  fact  is  always  present  to  the  mind 
of  the  sufferer  that  he  has  an  anus.  He  scarcely  ever 
feels  that  his  bowel  has  been  properly  relieved,  and  this 
feeling  often  leads  to  frequent  visits  to  the  closet,  and 
attempts  to  procure  satisfaction  by  straining,  which 
ultimately  aggravates  the  malady.  The  condition  of 


100 


INTERNAL  HAEMORRHOIDS 


the  sphincter  ani  plays  an  important  part  in  causing 
distress  ; if  it  be  strong  and  tight,  when  the  piles  come 
down,  they  get  nipped  and  their  return  is  rendered 
difficult  and  painful ; on  the  other  hand,  if  the  sphincter 
be  lax,  the  bowel  is  constantly  coming  outside  on  the 
slightest  exertion,  as  in  coughing,  stooping,  or  even 
walking ; and  in  these  cases  when  the  bowel  is  down, 
the  patient  can  seldom  retain  liquid  motions.  I fre- 
quently meet  with  patients  who  say  they  have  to  retire 
to  a urinal  and  push  up  the  protrusion  when  it  descends, 
or  they  cannot  walk  at  all.  The  employment,  of  course, 
has  much  to  do  with  the  discomfort  of  the  patient ; 
again,  constipation  adds  greatly  to  the  severity  of  the 
symptoms,  and  so  also  does  habitual  relaxation,  which, 
by  causing  frequent  protrusion  induces  inflammation 
and  ulceration  of  the  part.  These  advanced  haemor- 
rhoids are  almost  always  associated  with  cutaneous 
hypertrophies  around  the  anus,  and  these,  being 
irritated  by  the  discharges,  become  inflamed  and  very 
tender.  Sometimes  I have  seen  a number  of  polypoid 
growths  studded  over  the  mucous  membrane  at  the 
entrance  to  the  anus ; in  a patient  of  mine  at  St  Mark’s 
Hospital  I counted  twelve  of  these,  and  recently  I 
have  had  a private  patient  on  whom  I counted  twenty- 
two  excrescences. 

When  called  to  a patient  who  has  forced  his  piles 
down  and  cannot  return  them,  proceed  in  this  way : — 
Place  him  flat  on  his  face,  with  three  or  four  pillows 
under  his  pelvis,  to  raise  the  hips  well  up  and  allow  the 
intestines  to  gravitate  towards  the  chest ; then  smear 
the  piles  over  with  some  ointment,  pass  one  finger  into 
the  bowel,  and  with  the  other  hand  gently  apply 
pressure,  trying  to  empty  the  piles  of  their  superfluous 


INTERNAL  HAEMORRHOIDS 


101 


quantity  of  blood ; tbis  should  be  done  very  gently, 
as  you  would  apply  taxis  to  a hernia.  Should  this  not 
succeed,  place  a bladder  of  ice  over  the  part,  and  leave 
the  patient  in  the  position  I have  recommended  for 
an  hour ; then  try  taxis  again,  and  you  will  in  all  pro- 
bability return  the  mass.  I have  found  on  several 
occasions  that  freezing  with  the  ether-spray  has  been 
an  effective  and  more  rapid  method  of  inducing  con- 
traction temporarily,  and  removing  the  sensitiveness 
so  that  you  can  apply  more  direct  pressure,  but  I am 
bound  to  say  this  manoeuvre  is  usually  followed  by 
severe  burning  pain  in  the  rectum.  If  your  attempts 
at  replacing  the  piles  have  not  been  successful,  try  to 
persuade  the  patient  to  have  them  operated  upon 
without  delay  ; if  he  will  not  accede  to  this  proposal  you 
may  order  some  leeches  or  apply  moderate  cold.  If 
there  be  much  strangulation,  ice  should  not  be  kept  on 
very  long,  or  you  may  produce  more  sphacelus  than  you 
desire.  In  some  instances  warm  applications  with 
sedatives  are  more  comforting,  and  relieve  pain  sooner 
than  cold. 

For  my  own  part  I never  hesitate  to  operate  at  once 
if  I can  get  my  patient’s  consent ; a speedy  and  radical 
cure  of  the  disease  is  thus  obtained.  I never  saw  a 
case  of  this  kind  do  badly,  although  some  surgeons 
have  said  that  inflamed  haemorrhoids  should  not  be 
operated  upon.  I will  make  an  exception  in  cases  of 
protruded  piles  where  mortification  has  set  in  to  any 
extent ; here,  although  it  may  be  necessary  to  operate, 
care  must  be  taken,  as  the  tissues  are  so  broken  down 
that  the  ligatures  will  not  hold  and  hsemorrhage  may 
result.  In  a case  I had  in  the  practice  of  Dr  Tanner, 
of  Newington,  the  parts  were  so  friable  that  the  liga- 


102 


INTERNAL  HEMORRHOIDS 


tures  cut  through  the  piles,  and  there  was  considerable 
difficulty  in  arresting  the  bleeding ; I accomplished  it 
by  passing  a tenaculum  deeply  below  the  vessels  and 
applying  a ligature  around  it.  I then  cut  the  tenaculum 
away  from  the  handle  and  left  it  in  for  three  days. 
This  patient  did  exceedingly  well,  and  was  about  in 
less  than  a fortnight. 

In  old-standing  prolapsed  haemorrhoids  there  is  fre- 
quently a difficulty  in  retaining  wind  or  loose  motion  ; 
this  is  caused  in  part  by  the  relaxed,  weak  state  of  the 
sphincter,  but  more  particularly,  I believe,  by  the  loss 
of  the  acute  sensitiveness  of  the  mucous  membrane  at 
the  lower  part  of  the  rectum.  This  sensibility  in  the 
healthy  subject  gives  timely  warning  to  the  sphincter 
ani  to  contract  when  necessary. 

Yery  rarely  in  advanced  states  of  hsemorrhoidal 
disease  is  a cure  effected  without  having  recourse  to  an 
operation,  but  I have  seen  such  cases ; one  particularly 
recurs  to  my  mind,  from  the  fact  that  I had  given  a 
most  positive  opinion  that  no  permanent  benefit  could 
be  obtained  without  operating.  This  was  a gentleman 
past  middle  age,  who  had  suffered  for  years ; his  piles 
were  full-sized,  they  used  to  bleed  much,  and  always 
protruded  more  or  less  at  stool ; they  were  of  the 
venous  passive  form,  and  no  doubt  were  dependent  in 
some  degree  on  the  condition  of  the  liver.  In  this 
case  great  attention  to  the  state  of  the  bowels,  the 
patient  always  lying  down  to  have  an  action,  and  re- 
maining recumbent  for  an  hour  or  two  afterwards  ; care 
as  to  diet,  which  was  of  the  most  unstimulating  cha- 
racter, and  almost  devoid  of  alcohol ; smearing  the 
piles  over  with  the  subsulphate  of  iron  and  other 
astringent  ointments ; the  occasional  use  of  a full- 


INTERNAL  HAEMORRHOIDS 


103 


sized  bougie ; injection  of  a quarter  of  a pint  of  cold 
water  daily,  and  the  internal  administration  of  Ward’s 
paste,  tincture  of  the  muriate  of  iron,  and  other 
remedies,  in  about  four  years  effected  a cure.  At  least 
he  told  me  lately  that  he  had  no  trouble  now  with  his 
piles ; nothing  came  down  at  stool,  he  had  no  bleeding, 
and  suffered  no  other  inconvenience.  This  gentleman 
was,  I must  say,  able  to  command  every  comfort,  and 
was  never  in  any  way  compelled  to  exert  himself ; he 
had  an  insuperable  objection  to  anything  like  an  opera- 
tion, but  was  most  determined, persevering,  painstaking, 
and  intelligent  in  carrying  out  all  the  devices  I have 
mentioned.  Such  conditions  are  rarely  met  with  in 
ordinary  life ; and  therefore  for  all  practical  purposes 
it  may  be  said  that  an  operation  is  indispensable.  I 
have  since  this  case  met  with  others  of  a similar 
character,  and  some  have  yielded  to  general  treat- 
ment and  the  internal  use  of  the  chloride  of  ammo- 
nium. 

It  is  in  this  the  third  or  venous  kind  of  pile  that  I 
think  constitutional  treatment  most  likely  to  be  suc- 
cessful, not,  perhaps,  in  always  curing  the  disease,  but 
in  materially  alleviating  it,  as  the  malady  often  depends 
upon  uterine  or  liver  affections,  and  a generally 
overloaded  congested  condition  of  the  system  found  in 
those  who  habitually  eat  and  drink  too  much,  and  who 
take  but  little  exercise  ; these  causes  may,  to  a great 
extent,  if  not  altogether,  be  removed,  and  if  they  are 
so,  the  haemorrhoidal  disorder  will  be  found  to  be 
benefited  to  an  equal  degree.  A prolonged  course  of 
the  Friedrichshall  and  Carlsbad  waters  will  be  found 
useful.  I have  also  seen  benefit  derived  from  the  oil 
of  sandal  wood  taken  in  conjunction  with  such  reme- 


104 


INTERNAL  HAEMORRHOIDS 


dies  as  relieve  congestion  of  the  portal  system,  and 
depurate  the  blood  generally. 

Professor  Richet,  of  Paris,  at  the  Hotel  Dieu, 
delivered  a lecture  on  what  he  termed  “white  piles  ” 
(Jiemorrho'ides  blanches ),  as  they  did  not  discharge 
blood  like  ordinary  internal  haemorrhoids,  but  a sero- 
mucous  fluid.  The  professor  stated  that  the  white 
piles  are  merely  ordinary  piles  in  a more  advanced  stage, 
and  consisted  principally  of  hypertrophy  of  the  papil- 
lary bodies  of  the  mucous  membrane.  The  incessant 
discharge  acted  as  perniciously  as  frequent  bleeding, 
being  nothing  more  or  less  than  transformed  blood ; 
and  he  advised  them  to  be  operated  on  in  the  usual 
way,  preferring  himself  the  cautery  to  any  other 
method ; he  objected  to  Chassaignac’s  “ ecraseur,”  or 
Maisonneuve’s  wire  “ constricteur,”  which,  he  says, 
often  produce  permanent  contraction  of  the  anus.  For 
my  part,  while  agreeing  with  M.  Richet,  I do  not  see 
any  sufficient  reason  for  introducing  a new  name  in 
addition  to  those  generally  in  use. 

In  women  suffering  from  a retroverted  or  anteverted 
uterus  an  operation  upon  piles  is  very  undesirable, 
and  will  most  certainly  end  in  disappointment  unless 
the  uterine  complication  be  attended  to  at  the  same 
time,  or,  what  is  better,  prior  to  the  operation.  My 
experience  warrants  me  in  saying  that  if  you  can 
restore  the  uterus  to  its  normal  position  and  size,  you 
will  find  that  the  rectal  affection  will  soon  become  a 
comparatively  small  matter.  In  my  earlier  operations 
upon  women  I did  not  take  into  sufficient  consideration 
the  condition  of  the  uterus,  and  I could  relate  many 
cases  in  which  I was  most  grievously  annoyed  to  find 
that  the  patient  did  not  recover,  as  I anticipated  she 


INTERNAL  HAEMORRHOIDS 


105 


would  have  done.  I have  found  that  if  the  wounds 
heal  there  is  but  little  relief  afforded,  the  same 
bearing  down  and  distressing  sensation  exists  in  the 
bowel  as  it  did  before  the  removal  of  the  piles.  More 
commonly  the  wounds  do  not  heal,  and  very  painful 
unhealthy  ulceration  follows ; this  will  never  get  well 
as  long  as  the  abnormal  condition  of  the  uterus 
remains.  I will  briefly  relate  a case  or  two  bearing 
upon  this  point. 

Mary  C — , set.  34,  came  under  my  care,  in  the  early  part  of  the  year 
1862,  at  the  Farringdon  Dispensary.  She  was  a single  woman,  and  had 
suffered  for  years  from  haemorrhoids ; they  came  down  at  stool ; she 
lost  blood  and  had  much  bearing  down ; she  was  likewise  troubled  with 
her  water,  passed  it  very  frequently  and  with  difficulty,  never  feeling 
that  she  had  quite  emptied  her  bladder.  The  urine  was  not  turbid,  and 
she  did  not  have  actual  pain — only  discomfort.  On  examination  four 
full-sized  haemorrhoids  were  found  (their  character  is  not  stated  in  my 
note  book).  Aided  by  my  friends  Dr  Frodsham  and  Mr  Charles  Smith, 
I applied  ligatures  to  them.  The  operation  was  followed  by  retention 
of  urine,  and  a catheter  had  to  be  passed  for  the  first  few  days ; while 
she  was  in  bed  she  seemed  better,  but  after  a fortnight,  when  she  began 
to  get  about,  she  complained  of  bearing  down  in  the  “ back  passage,” 
and  much  pain  in  defaecation.  The  bowels  were  very  difficult  to  get  to 
act.  These  symptoms  I had  expected  would  pass  away  when  the  wounds 
were  quite  healed ; but,  to  my  dismay,  they  did  not,  and  two  months 
after  the  operation  I found  there  was  ulceration  of  the  bowel,  and  she 
suffered  a great  deal.  I had  for  some  time  suspected  that  the  uterus 
was  not  right,  so  I obtained  the  opinion  of  Dr  Edward  Cock,  who  was 
at  that  time  the  obstetric  physician  to  the  Dispensary,  and  that 
gentleman  pronounced  that  she  had  a fibroid  tumour  of  the  uterus 
(this  diagnosis  was  afterwards  confirmed  by  many  other  authorities). 
I need  not  prolong  this  history — suffice  it  to  say  that  she  never  got 
well ; for  years  I saw  her  occasionally ; she  always  had  rectal  symptoms 
and  suffered  a great  deal  of  pain.  I do  not  think  the  ulceration  of 
the  bowel  ever  entirely  healed.  I took  her  into  St  Mark’s  Hospital  in 
the  year  1867,  and  by  rest  and  treatment  she  got  better,  but  not  well ; 
for  the  last  three  years  I have  lost  sight  of  her.  I believe  she  gained 
admittance  into  one  of  the  hospitals  for  incurables.  I am  quite  certain 
of  one  thing,  i.  e.  she  was  not  benefited,  and  I am  strongly  of  opinion 
that  she  was  damaged  by  the  operation  I performed  upon  her. 


106 


INTERNAL  HEMORRHOIDS 


Emma  N — was  admitted  into  the  Great  Northern  Hospital  under  my 
care  in  February  of  1864 ; she  was  a single  woman,  set.  24.  She  com- 
plained of  great  pain  in  passing  her  motions  ; the  pain  lasted  for  hours, 
and  then  gradually  subsided,  and  she  was  easy  until  she  had  again  to 
go  to  stool.  Of  course  my  diagnosis  was  fissure,  and  I was  correct,  but 
in  addition  I found  three  large  internal  arterial  haemorrhoids.  I incised 
the  fissure  and  tied  the  piles.  She  went  on  very  well  and  left  the 
hospital,  feeling  quite  comfortable,  and  being  free  from  pain  on  the 
bowels  acting.  In  about  a month  she  came  again  to  me,  saying  that  her 
old  symptoms  had  returned,  but,  on  examination,  I could  find  no  fissure 
or  ulceration,  or  anything  the  matter  with  the  rectum  ; she  complained 
of  pain  and  straining  when  the  bowels  acted,  and  a sensation  of  not 
being  relieved  afterwards.  The  only  thing  I could  find  to  account  for 
this  was  a tendency  to  intussusception  of  the  upper  part  of  the  rectum 
on  her  bearing  down.  I treated  her  with  laxatives,  sedative  injections, 
suppositories,  and  other  remedies,  but  with  very  little  benefit ; what 
seemed  to  do  her  most  good  was  rest  in  bed.  Suspecting  uterine  dis- 
ease, I recommended  her  to  see  an  obstetric  physician,  and  she  came 
under  the  care  of  my  friend  Dr  Palfrey,  and  that  gentleman  found  that 
she  had  retroflexion  of  the  uterus.  She  was  under  his  charge  for  a very 
long  period,  and  underwent  some  operative  treatment  at  the  London 
Hospital.  After  this  I took  her  into  St.  Mark’s  Hospital,  but  could 
never  find  any  organic  mischief  in  the  rectum,  although  she  still 
suffered  pain  and  much  discomfort  in  connection  with  defsecation.  I 
have  recently  heard  that  this  patient  is  now  better,  but  for  years  she 
was  incapable  of  doing  any  work.  It  was  said  that  masturbation  was 
the  primary  cause  of  this  woman’s  suffering ; it  might  be  so,  but  I 
cannot  say  that  I am  prepared  to  endorse  that  opinion. 

Mrs  It — , a patient  of  my  friend  Mr  Charles  Waller,  of  Sydenham, 
was  operated  upon  by  me  for  severe  haemorrhoids,  Mr  Waller  assisting 
me.  I knew  this  lady  was  suffering  at  the  same  time  from  vaginismus, 
but  I thought  that  the  removal  of  the  rectal  disease  might  be  generally 
beneficial  to  her  health,  which  was  very  much  deteriorated  by  the  losses 
of  blood  she  sustained.  After  the  operation  she  was  much  better  for  a 
few  weeks,  but  the  wounds  in  the  bowel  healed  with  great  difficulty, 
and  after  some  time  she  had  a good  deal  of  pain  on  defsecation,  and 
the  bowels  were  very  confined ; I could  not  discover  any  disease  of  the 
rectum,  although  her  symptoms  were  directly  referable  to  that  organ. 
A year  or  so  later  she  was  operated  upon  by  Dr  Barnes  for  the  cure  of 
the  vaginismus  ; but  I know  that  she  has  never  recovered  good  health, 
and  is  an  invalid  to  this  day,  her  sufferings  being  most  prominently 
rectal. 

Tripartite  disease  of  the  rectum,  uterus,  and  bladder 


INTERNAL  HAEMORRHOIDS 


107 


or  urethra,  is  very  common.  I attended  a lady  of 
middle  age,  who  had  haemorrhoids  and  fissure ; after 
the  operation  she  still  suffered  pains  in  the  rectum 
and  I suspected  disease  of  the  womb,  as  she  had 
difficult  and  painful  menstruation.  She  was  seen  by  a 
distinguished  gynaecologist,  who  found  a contracted  os 
uteri,  and  she  underwent  an  operation  which  for  a 
time  did  good ; then  she  suffered  from  spasm  of  the 
urethra  and  great  pain  on  micturition.  Dilatation  of 
the  urethra  was  performed  also  with  temporary  benefit, 
but  her  rectum,  although  perfectly  sound,  was  every 
now  and  again  very  painful,  and  always  so  at  her  men- 
strual period.  I know  this  lady  consulted  most  of  the 
eminent  men  in  London,  and  had  all  kinds  of  treat- 
ment, and  still  she  comes  to  me  from  time  to  time, 
and  it  is  quite  five  years  since  I first  saw  her,  with  all 
her  old  symptoms,  not  merely  subjective,  but  objective, 
as  inflammation  of  the  rectum,  uterus,  bladder,  and 
urethra — one  or  all  at  the  same  time. 

I Rave  Rad  a lady  under  my  care,  sent  me  by  my  friend  Dr  Leeson, 
wRo  suffered  from  subinvolution  of  tRe  uterus,  witR  ulceration  of  tRe 
os  and  painful  profuse  menstruation  ; sRe  Rad  also  RsemorrRoids,  wRicR 
prolapsed  and  bled,  and  a circular  ulcer  in  tRe  bowel.  It  was  agreed 
tRat  an  operation  sRould  be  performed,  and  I removed  Rer  RsemorrRoids 
witR  tRe  clamp  and  cautery,  and  incised  tRe  ulcer.  TRe  Realing  was 
most  difficult  and  tedious  ; ulceration  took  place,  and  sucR  contraction 
as  to  cause  stricture,  wRicR  after  some  montRs  I was  compelled  to 
divide.  SRe  also  acquired  inflammation  of  tRe  bladder,  after  Raving  a 
catReter  passed  only  a few  times,  so  tRat  great  pain  on  micturition 
was  added  to  Rer  otRer  troubles ; only  after  tRe  most  constant  attention, 
and  compelling  Rer  to  occupy  tRe  recumbent  position  for  more  tRan 
four  montRs,  did  slie  recover.  Parallel  cases  are  so  common  witR  me, 
tRat  I could  relate  many  more,  but  I only  want  to  sRow  Row  complicated 
and  difficult  to  treat  tRese  cases  are. 

In  cases  of  hemorrhoids  in  persons  with  congested 
livers,  or  who  habitually  eat  and  drink  too  much,  I 


108 


INTERNAL  HAEMORRHOIDS 


make  a rule  of  administering  every  night  before  the 
operation  (for  three  or  four  nights)  a five- grain  blue  pill, 
and  in  the  morning  a modification  of  the  old-fashioned 
black  draught.  This  may  seem  to  be  rather  rough 
treatment,  but  I see  the  most  beneficial  results  accrue 
from  it ; and  I am  confident  that  patients  thus  served 
do  better  than  many  others ; again  and  again  I have 
been  perfectly  astonished  at  the  rapidity  with  which 
they  recover.  My  friend  Dr  David  Young,  of  Florence, 
has  recommended  glycerine  to  be  taken  internally  as 
an  effective  remedy  in  haemorrhoids,  even  of  advanced 
growths.  Knowing  what  an  accurate  observer  Dr 
Young  is,  I have  now  in  many  hundreds  of  cases  pre- 
scribed his  remedy,  but  I am  bound  to  say  without  any 
marked  success,  although  I have  persevered  with  it 
for  months  continuously. 


CHAPTER  IX 

OPERATIONS  UPON  INTERNAL  HEMORRHOIDS 

When  you  have  determined  that  there  is  no  constitu- 
tional impediment,  and  that  an  operation  is  positively 
necessary  to  effect  the  cure  of  your  patient,  you  will 
then  have  to  decide  what  proceeding  will  be  best 
suited  to  the  case  you  have  in  hand.  From  this  you 
will  conclude  that,  in  my  opinion,  no  particular  method 
of  operating  can  be  always  wisely  employed  to  the 
exclusion  of  all  other  modes. 

There  are  several  distinct  operations  and  modifica- 
tions of  them  from  which  to  choose,  and  most  of  them 
have  been  advocated  by  surgeons  of  repute,  well  skilled 
in  their  art,  and  worthy  of  consideration.  I shall  first 
name  the  operations  and  then  proceed  to  describe  them, 
and  I trust  fairly  to  express  my  opinion  as  to  their 
various  merits  or  demerits. 

1.  Excision  with  knife  or  scissors. 

2.  The  ecraseur  of  Chassaignac  or  the  wire  of 
Maisonneuve. 

3.  The  application  of  various  acids  and  caustic 
pastes. 

4.  The  injection  of  carbolic  acid  or  other  caustic  or 
astringent  fluids  into  the  body  of  the  pile. 


110  OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS 

5.  Cauterization,  “ ponctuee  ” of  Demarquay,  Mr 
Reeves,  and  others. 

6.  Cauterization,  “ linear  ” of  Woillemier. 

7.  Removal  by  the  galvanic  cautery  wire. 

8.  Removal  by  the  clamp  and  scissors,  applying  the 
actual  cautery  to  arrest  haemorrhage. 

9.  Dilatation  of  the  sphincter  muscles. 

10.  Removal  by  means  of  the  screw-crusher. 

11.  Ligature. 

I.  Excision  by  the  Jcnife  or  scissors 

In  days  gone  by  excision  was  performed  by 
Dupuytren,  Sir  Astley  Cooper,  and  others,  but  they  all 
acknowledged  the  danger  of  the  operation,  and  many 
fatal  cases  are  recorded  as  having  occurred  even  in  the 
hands  of  masters  in  surgery.  With  our  newly  devised 
modes  of  operating,  and  especially  of  arresting  haemor- 
rhage, we  can  now  in  many  cases  perform  the  operation 
of  excision  without  incurring  any  extraordinary  danger, 
and  therefore  it  need  not  be  summarily  dismissed  from 
our  consideration. 

For  my  own  part,  I think  it  is  one  of  our  best  opera- 
tions, and  I have  now  records  of  seventy  cases  in 
which  I excised  internal  piles  with  remarkably  good 
results.  Little  pain  has  been  experienced,  and  the 
recovery  has  been  so  rapid  that  nearly  all  my  patients 
have  been  absolutely  well  by  the  sixth  day ; by  this  I 
mean  that  the  wounds  were  all  soundly  healed.  I 


OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS  111 


consider  this  the  only  test  of  perfect  recovery — to  say 
that  they  were  convalescent  and  could  go  about  would 
not  express  the  whole  truth — the  word  44  convales- 
cence ” is  very  elastic  as  regards  its  significance,  and  is 
often  erroneously  used  as  synonymous  with  64  cured.” 
I do  not  recommend  excision  in  cases  where  the 
haemorrhoids  are  very  large  or  unusually  numerous. 
In  my  cases  there  existed  one,  two,  or  at  most  four 
piles.  In  performing  excision  I first  gently  but  fully 
dilate  the  sphincter  muscles,  and  employ  a retractor 
to  keep  the  anus  well  open ; I then  seize  the  pile  deeply 
by  its  base,  cut  it  off  above  the  level  of  the  vulsellum, 
and  do  not  let  it  go  until  all  bleeding  is  arrested  by 
torsion  of  the  arteries ; rarely  more  than  two  vessels 
spout  and  require  twisting.  I wait  for  a little  while 
to  see  that  all  bleeding  has  ceased,  and  then  I treat 
the  other  piles  in  a similar  manner.  After  all  the 
arteries  have  ceased  to  bleed,  I place  a piece  of  cotton 
wadding,  previously  saturated  in  a solution  of  tannin 
and  water  (strength,  one  ounce  of  tannin  to  one  ounce 
of  water),  within  the  anus  as  high  as  my  scissors  have 
cut.  In  no  case  did  any  recurrent  haemorrhage  take 
place.  This  operation  must  be  done  slowly  and  care- 
fully, and  therefore  occupies  more  than  the  usual  time, 
which,  however,  is  of  no  moment  as  the  patient  is 
insensible.  As  far  as  my  present  experience  can  lead 
me  to  judge,  I am  of  opinion  that  numerous  cases  are 
amenable  to  this  treatment.  The  single  perineal 
haemorrhoid,  so  frequently  found  in  women,  is  peculiarly 
well  suited  to  this  operation.  I have  used  several  times 
the  ingenious  toothed  scissors  of  Dr  Richardson,  but 
I do  not  like  them.  The  theory  upon  which  they  have 
been  constructed  is  excellent,  but  the  practice  is  bad, 


112  OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS 

the  haamorrhage  is  not  always  controlled,  and  often 
very  nasty  irritable  wounds  result. 


II.  The  chain  or  wire  ecraseur . 

I really  do  not  know  any  sufficient  reason  for  the 
continued  practice  of  this  mode  of  operating  on  piles. 
I have  called  it  “ barbarous  and  unsurgical,”  and  I 
cannot  see  why  I should  modify  that  expression.  The 
chain  is  undoubtedly  worse  than  the  wire,  but  neither 
is  definite  in  its  action ; they  remove  either  too  much 
or  too  little.  Thus  I have  seen  several  cases  of  most 
intractable  stricture  follow,  and,  on  the  other  hand, 
cases  in  which  nothing  curative  had  resulted,  a timid 
operator  taking  away  only  two  or  three  portions  of 
mucous  membrane,  and  really  leaving  the  haemor- 
rhoids almost  untouched.  A Brazilian  gentleman 
was  sent  to  me  eight  weeks  after  he  had  been  ope- 
rated on  by  a distinguished  French  surgeon  with  the 
ecraseur,  the  hasmorrhoids  still  existed  in  abundance, 
and  he  was  losing  much  blood.  I have  seen  at  least 
half  a dozen  such  failures.  A metropolitan  sur- 
geon of  eminence  told  me  he  had  obtained  success 
with  the  ecraseur,  but  upon  interrogation  his  idea  of 
success  did  not  come  up  to  my  notion  of  the  word. 
Another  objection  to  the  ecraseur  in  haemorrhoids  is 
the  intense  and  prolonged  pain  which  follows,  espe- 
cially when  skin  is  removed.  An  Italian  surgeon  re- 
lated to  me  a case  where  death  ensued  in  a woman  from 
shock  and  pain  in  less  than  twenty-four  hours,  and  I 
can  quite  credit  his  statement.  I once  saw  a woman 
die  in  St  Thomas’s  Hospital  from  the  same  cause  after 


OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS  113 

an  operation  by  ligature  applied  in  the  old  way,  I mean 
by  transfixion  and  ligature  of  skin  as  well  as  haemor- 
rhoids. The  patient  was  operated  upon  by  Mr  Simon 
on  the  19th  of  November,  1859.  She  was  a pale,  feeble 
woman,  set.  53;  she  died  on  the  morning  of  the  next  day; 
she  had  suffered  intensely.  I have  no  note  of  what  was 
done  to  relieve  the  pain.  The  post-mortem  examination, 
made  by  Mr  Sydney  Jones  on  the  21st,  was  as  follows  : 

“ Some  piles  had  been  the  subject  of  operation  by 
ligature — the  ligatures  were  present.  Nothing  ab- 
normal was  detected  in  the  veins  leading  from  the 
ligatured  piles.  The  thoracic  viscera  were  healthy. 
There  was  some  congestion  of  the  posterior  part  of 
the  lungs.  The  liver  was  rather  large  and  pale.  The 
kidneys  were  healthy.  The  peritoneum  and  intestines 
were  quite  healthy.” 

I do  not  think  the  death  in  this  case  could  be  attri- 
buted to  anything  but  shock  and  exhaustion  from 
excessive  pain. 


III.  The  application  of  various  acids  and  caustic  pastes 

The  treatment  of  haemorrhoids  by  acids  or  caustics 
may  scarcely  seem  to  justify  the  use  of  the  term 
“ operation,”  but  as  some  manual  dexterity  is  necessary 
in  order  to  apply  them  properly,  I must  beg  permission 
of  my  readers  to  allude  to  them  here.  For  many  years 
acids  have  been  used  in  attempts  either  to  destroy  or 
cause  such  consolidation  in  piles  as  should  lead  to  their 
cure.  The  acids  chiefly  used  have  been  the  fuming 
nitric  acid,  the  acid  nitrate  of  mercury,  chromic,  and 
more  recently  carbolic  acid.  It  was  thought  at  one 

8 


114  OPERATIONS  UPON  INTERNAL  HEMORRHOIDS 

time  tliat  even  large  piles  could  be  destroyed  by  acids, 
and  many  cures  were  published,  but  I very  much  doubt 
if  any  lasting  cures  of  developed  haemorrhoids  were 
effected  by  such  means.  I have  seen  numbers  of  cases 
in  which  the  attempt  was  made,  but  the  patients  were 
either  not  relieved  at  all,  or  only  very  temporarily 
benefited.  Haemorrhage  was  often  arrested,  but  it 
generally  recurred,  and  on  many  occasions,  after  the 
free  use  of  acid,  violent  bleeding  took  place  on  the 
separation  of  the  sloughs,  and  patients  were  brought 
nearly  to  death’s  door.  If  the  application  of  acids 
were  restricted  to  cases  of  small  granular  piles,  or 
patches  of  villous  bleeding  mucous  membrane,  I should 
not  object  to  their  use,  as  often  patients  will  submit 
to  such  treatment  when  they  will  not  to  anything 
more  formidable,  and  relief  and  even  cure  in  this 
stage  of  the  disease  may  be  obtained;  but  no  satis- 
faction can  result  from  touching  large  haemorrhoids 
with  any  acid  known  to  me.  A few  years  ago  I had 
an  opportunity  of  testing  all  the  acids  I have  men- 
tioned in  the  case  of  an  old  Indian  general,  who  had 
three  prolapsed  arterial  haemorrhoids  of  vascular  sur- 
face and  considerable  size.  His  shattered  health,  with 
partial  paralysis,  forbade  any  serious  operation,  and 
he  was  unwilling  that  more  than  external  applications 
should  be  made.  For  three  months  I persevered;  I 
managed  not  to  cause  him  much  pain,  though  the 
diseased  mucous  surfaces  were  painted  freely  and  fre- 
quently. The  method  in  which  I applied  the  acids  I 
will  mention,  as  I think  it  a good  way  to  avoid  pain. 
The  piles  being  fully  prolapsed  (he  could  strain  them 
down  easily),  I surrounded  one  with  a piece  of  wool 
soaked  in  a saturated  solution  of  bicarbonate  of  soda, 


OPERATIONS  UPON  INTERNAL  HEMORRHOIDS  115 

the  surface  of  the  pile  was  then  dried,  and  the  acid 
applied  with  a small  wooden  brush  several  times, 
waiting  between  the  applications  for  the  part  to  dry. 
Each  pile  being  thus  treated  the  parts  were  washed, 
well  oiled,  and  returned  within  the  sphincters.  On 
one  or  two  occasions  troublesome  bleeding  followed 
the  separation  of  a slough,  but  usually  it  came  away 
in  small  portions ; by  this  mode  of  using  the  acids  I 
never  caused  any  burning  of  skin  or  healthy  struc- 
ture. At  times  the  patient  thought  himself  better,  but 
the  final  result  was  a failure. 

I came  to  the  conclusion  that  the  chromic  and  car- 
bolic acids  were  better  agents  than  nitric  acid  and  acid 
nitrate  of  mercury.  Still  more  recently  I had  a good 
trial  with  acids  on  a gentleman  who  had  one  haemor- 
rhoid placed  anteriorly,  which  was  always  prolapsed  and 
consequently  bled,  and  gave  him  much  annoyance,  but 
no  great  pain.  I really  expected  to  obtain  a fair  result 
here,  but  all  failed.  My  friend  Dr  B.  W.  Richardson 
had  recommended  me  to  try  the  application  of  his 
“ Iodized  Colloid  ” as  a remedy  in  internal  haemor- 
rhoids ; he  told  me  the  resulting  pain  would  be  con- 
siderable, but  that  a dozen  touches  would  generally 
suffice  for  the  cure.  I made  trial  of  this  in  the  above 
case,  but  the  pain  experienced  was  so  great  that  my 
patient  became  restive  and  refused  to  persevere ; while 
in  that  humour  I suddenly  proposed  to  excise  the  offend- 
ing pile,  he  consented,  I at  once  removed  it,  twisted 
the  vessels,  and  he  was  quite  well  in  a few  days. 

Caustic  'pastes . — Personally  I have  no  experience  of 
this  practice  as  applied  to  haemorrhoids,  but  in  France 
and  Germany  it  has  been  freely  recommended ; to*  my 
mind  the  uncertainty  of  the  result,  added  to  the  great 


116  OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS 

pain  inflicted  by  caustics,  is  sufficient  to  deter  me  from 
using  them. 

Caustic  pastes  are  mostly  formed  by  adding  an  inert 
material  to  some  chlorides,  zinc,  calcium,  &c.  Bicord’s 
paste  (sulphuric  acid  and  carbon)  is  a favourite  with 
some  surgeons. 

Dr  Laroyenne,of  Paris,  in  the  c Gazette Hebdomadaire 
de  Medecine,’  No.  34,  1872,  passes  in  review  the  usual 
methods  of  treating  bleeding  internal  piles,  and  con- 
siders them  all  to  have  many  objectionable  features  and 
dangers,  and  recommends,  as  Bonnet  and  Valette  have 
done,  the  use  of  Vienna  paste  and  chloride  of  zinc; 
but  instead  of  applying  the  caustic  all  over  the  pile,  he 
uses  it  in  the  following  manner.  When  the  part  is 
prolapsed  several  lines  are  drawn  along  the  surface  of 
each  haemorrhoid  with  Vienna  paste,  the  lines  converg- 
ing towards  the  orifice  of  the  anus.  After  two  or  three 
minutes,  the  application  is  followed  by  placing  small 
fragments  of  chloride  of  zinc  paste  where  the  Vienna 
paste  has  been.  Eight  or  ten  caustic  lines  are  sufficient 
to  cure  the  largest  prolapsus.  In  this  manner  deep 
radiating  cauterisations  are  produced  without  de- 
stroying much  of  the  surface  of  the  piles.  The  appli- 
cation remains  for  seven  or  eight  hours.  The  only 
painful  period,  says  Dr  Laroyenne,  is  during  the 
application  of  the  Vienna  paste.  He  has  employed 
this  method  fourteen  times  without  the  slightest  ill 
effects  resulting,  all  the  patients  being  cured,  and  he 
believes  the  treatment  to  be  less  often  followed  by 
haemorrhage,  pyaemia,  and  other  accidents  than  any 
other.  I am  sorry  I cannot  concur  with  Dr  Laroyenne, 
and  submit  that  his  experience  is  far  too  small  to 
justify  his  belief. 


OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS  117 


IY.  The  injection  of  carbolic  acid  or  other  fluids  into 
the  substance  of  the  joile 

I have  read  in  American  pamphlets  that  the  injection 
of  carbolic  acid  into  internal  piles  for  the  purpose  of 
effecting  radical  cures  is  very  commonly  practised  in 
America,  and  that  “ shoals  of  quacks”  perambulate  the 
country,  armed  with  a hypodermic  syringe,  and  a bottle 
containing  a so-called  secret  remedy,  this  remedy  being 
carbolic  acid  diluted  in  different  ways  and  of  differing 
strength  ; the  favourite  formula  is  equal  parts  of  strong 
carbolic  acid,  glycerine  and  water.  This  treatment  is 
strongly  advocated  by  Dr  Cook,  of  the  Kentucky  School 
of  Medicine,  who  obligingly  sent  me  his  essay  upon  the 
subject.  I most  sincerely  hope  he  is  in  error  as  to  the 
“ shoals  of  quacks  ” who  employ  this  remedy  ; but  if 
radical  cures  are  effected,  and  no  evil  results,  the  only 
objection  I can  see  is  that  the  legitimate  practitioner 
loses  his  fees. 

After  carefully  reading  Dr  Cook’s  pamphlet  I did  not 
feel  quite  satisfied  that  he  had  made  out  a good  case 
for  the  carbolic-acid  treatment,  in  fact,  he  only  relates 
the  histories  of  two  persons  on  whom  he  had  performed 
injection;  he  generally  uses  the  formula  I have  men- 
tioned, and  squirts  through  a large  needle  ten  to 
twenty  drops  of  the  solution  into  the  substance  of  the 
pile ; he  does  not  inject  all  the  haemorrhoids  at  once, 
but  one  or  two  at  a time  every  other  day  until  all  are 
done.  Many  American  surgeons  who  come  to  see  the 
practice  at  St  Mark’s  have  repudiated  the  treatment  in 
round  terms,  and  call  it  uncertain  and  dangerous.  Dr 
Matthews,  of  Louisville,  has  kindly  sent  me  his  pam- 


118  OPERATIONS  UPON  INTERNAL  HEMORRHOIDS 

phlet,  read  before  the  Kentucky  State  Medical  Society 
in  1878,  and  in  tbat  paper  be  endeavours  to  show  that 
tbe  injection  of  tbe  acid  into  a pile  is  painful  and 
inefficient,  and  tbat  death  is  to  be  feared  {a)  from  peri- 
tonitis, ( b ) from  embolism,  (c)  from  pyaemia.  In  support 
of  bis  assertion  he  relates  a case  under  tbe  care  of 
another  practitioner,  where  in  twelve  hours  violent 
inflammation  followed,  but  the  piles  were  not  cured,  for 
in  twenty  days  after  the  injection  one  tumour  had  to 
be  removed  by  ligature.  He  also  cites  another  case  of 
peritoneal  inflammation,  and  says  embolism  and 
pyaemia  have  been  known  to  result  from  injecting  naevi 
with  solution  of  iron,  and  deaths  have  occurred  from 
injecting  internal  haemorrhoids  with  carbolic  acid.  For 
my  own  part  I am  much  inclined  to  agree  with  the 
opinion  of  Dr  Matthews.  I tried  the  injection  plan 
on  some  few  cases,  but  the  result  was  much  pain,  more 
inflammation  than  was  desirable,  a lengthy  treatment, 
and  the  result  doubtful ; certainly  not  a radical  cure. 

It  appears  to  me  that  all  attempts  to  destroy 
vascular  growths  by  causing  coagulation  of  blood  or 
inflammation  in  them,  while  they  are  not  shut  off  from 
the  general  circulation,  must  be  fraught  with  danger. 
You  can  have  no  guarantee  that  the  coagulum  may 
not  break  down,  and  minute  particles  of  dead  tissue 
find  their  way  into  the  vascular  or  lymphatic  systems, 
and  result  in  embolism  or  pyasmia,  or  both.  Per- 
chloride  and  persulphate  of  iron  in  solution  have  been 
used  in  the  same  manner  as  carbolic  acid,  but  a 
similar  risk  is  connected  with  them,  and  this  I submit 
far  outweighs  the  advantages  they  are  said  to  offer. 


OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS  119 


Y.  Cauterisation  “ Ponctuee” 

As  far  as  I can  ascertain,  M.  Demarquay,  in  the 
year  1868,  practised  and  strongly  advocated  the  use  of 
a red-hot  cautery  as  a cure  for  internal  haemorrhoids, 
the  iron  was  to  be  thrust  deeply  into  the  pile  twice  or 
thrice ; he  had  not  much  success.  I have  been  in- 
formed by  several  friends  in  military  and  civil  prac- 
tice that  the  native  doctors  in  China  and  some  parts 
of  India  treat  haemorrhoids  according  to  the  plan  of 
M.  Demarquay,  and  possibly  have  done  so  for  hun- 
dreds of  years.  My  informants  have  not  been  able  to 
satisfy  me  as  to  the  results  of  the  treatment,  only 
my  friend  Dr  Beaumont  said,  Cf  he  thought  that  many 
died.” 

In  1873  Enrico  Bottini,  of  Novare,  published  a 
thesis  entitled  66  La  galvanico  caustico  nella  practica 
Chirurgica.”  I make  the  following  extract  on  haemor- 
rhoids : — “ The  operator,  providing  himself  with  a gal- 
vanic cautery  heated  to  a fine  red,  applies  the  point  of 
it  to  the  liaemorrhoidal  tumour,  and  introduces  it  slowly 
and  progressively  to  a depth  varying  from  ten  to  fifteen 
millimetres.  When  the  point  of  fire  has  arrived  in  the 
interior  of  the  tumour  he  moves  it  around,  allows  it  to 
remain  for  a few  seconds,  and  then  rotates  as  it  is 
withdrawn;  he  repeats  the  treatment  in  the  same 
manner  and  with  equal  precautions  to  all  the  piles.  If 
the  tumours  are  extensive  he  again  introduces  the 
cautery  parallel  to  the  rectum.”  A case  of  pyaemia 
following  this  operation  is  related  in  full  detail  by 
Yerneuil.  A similar  operation  was  performed  in  1873 
by  E.  Lartisen,  a pupil  of  Yerneuil.  Mr  Beeves,  of  the 


120  OPERATIONS  UPON  INTERNAL  HEMORRHOIDS 

Hospital  for  Diseases  of  Women,  lias  brought  this 
method  forward  in  an  article  in  the  6 Lancet 5 of  Feb., 
1877.  He  calls  it  “immediate’*  and  “new;*’  the  one 
is  just  as  correct  a definition  as  the  other.  Wishing 
to  see  whether  the  conical  cautery  attached  to  the 
t£  Paquelin  ” instrument  was  better  than  the  hot  iron  of 
Demarquay  or  the  Chinese,  within  a fyj^night  of  the 
appearance  of  Mr  Reeve’s  paper  I used  it  in  three  cases. 
One  was  a patient  of  Dr  Hills,  of  Abbey  Road,  St  John’s 
Wood,  another  was  a case  which  I left  to  the  care  of 
the  late  Mr  Ernest  Carr  Jackson,  seeing  him  only  twice 
or  so  myself,  and  the  third  was  a hospital  patient.  I 
am  bound  to  say  that,  although  Meyer  and  Meltzer 
made  my  cautery,  and  I rigidly  followed  Mr  Reeve’s 
directions,  these  cases  were  all  failures — great  pain,  re- 
tarded recovery,  and  abscesses  occurred  in  two ; in  one 
a cure  did  not  result.  I was  only  pleased  nothing  worse 
happened,  as  the  same  objection  applies  to  this  mode 
of  treatment  as  I brought  against  the  use  of  injections 
of  acids  into  piles,  viz.  you  produce  a slough  or  in- 
flammation, the  extent  of  which  you  cannot  measure 
or  control,  in  the  interior  of  a vascular  tumour  not  cut 
off  from  the  general  circulation. 


VI.  Cauterisation , “ linear ,”  of  Woillemier 

The  operation  of  Woillemier,  I think,  is  (c  unique,” 
and  I feel  I cannot  do  better  than  translate  from 
6 L’Union  Medicale  ’ (1874)  such  portions  of  his  lecture 
as  shall  make  his  method  quite  clear  to  my  reader. 

I must  express  my  pleasure  at  the  straightforward 
manner  in  which  M.  Woillemier  describes  the  ad  van- 


OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS  121 

tages  and  disadvantages  of  his  operation.  He  does 
not  hesitate  to  say  that  the  patient  may  be  one  month 
in  getting  well,  he  states  that  in  very  bad  cases  two 
operations  may  be  necssary,  and  further  considers  the 
dangers  which  may  arise. 

“ The  patient,  whose  rectum  has  been  emptied  in 
the  morning  by  means  of  an  injection,  ought  to  be 
chloroformed ; but  if  he  prefer  to  remain  awake,  it  is 
of  little  importance,  as  the  operation  lasts  only  some 
seconds.  He  is.  laid  on  an  edge  of  the  bed,  with  one 
leg  extended,  and  the  other  bent  as  if  he  were  going  to 
be  operated  on  for  fistula.  The  assistant  raises  the 
disengaged  buttock,  the  surgeon  paints  the  anus  and  the 
surrounding  parts  freely  with  collodion,  whilst  another 
assistant,  by  means  of  bellows,  drives  off  the  fumes  of 
the  ether,  which  are  sure  to  catch  fire  when  a highly 
heated  cauteriser  is  brought  near  them.  During  these 
preparations,  two  knife-shaped  cauterisers  have  been 
placed  in  a small  furnace,  full  of  charcoal  or  burning 
wood.  The  blades  of  these  cauterisers  should  be  two 
centimetres  long  and  one  wide ; the  tip  and  edge  should 
be  blunt,  as  in  ordinary  cauterisers,  but  the  back 
should  be  four  or  five  millimetres  thick,  so  as  to  hold 
enough  heat.  The  surgeon  takes  one  of  these  caute- 
risers when  it  is  white  hot,  and  introduces  it  about 
one  centimetre  into  the  anus,  bearing  with  the  shoulder 
of  the  instrument  rather  more  on  the  cutaneous  than 
on  the  mucous  orifice,  and  makes  four  cauterisation 
lines,  before,  behind,  on  the  right,  and  on  the  left. 
The  operation  is  terminated  when  it  has  lasted  five  or 
six  seconds.  The  patient  is  brought  back  to  con- 
sciousness, and  simple  water  dressings  only  are  applied 
to  the  anus.  We  must  premise  that,  under  the  in- 


122  OPERATIONS  UPON  INTERNAL  HEMORRHOIDS 

fluence  of  the  congestion  produced  by  cauterisation, 
the  hasmorrhoidal  tumour  will  reappear  the  first  day 
or  so,  and  may  sometimes  be  larger  than  usual,  but  no 
notice  need  be  taken  of  it.  We  can  relieve  the  pain  of 
the  patient,  pain  which  has  no  relation  to  the  cauterisa- 
tion, only  by  coating  over  the  haemorrhoids  with  a nar- 
cotic ointment,  and  covering  them  up  with  a poultice. 
The  tumour  soon  ceases  to  be  painful,  and  is  at  last 
completely  and  spontaneously  retracted.  The  time 
necessary  for  cure  varies  only  according  to  the  size  of 
the  haemorrhoids,  the  relaxation  of  the  anus,  and  the 
age  of  the  patient.  It  has  never  exceeded  one  month, 
and  has  sometimes  been  much  less.  In  some  subjects, 
even  when  circumstances  have  made  success  doubtful, 
cure  has  taken  place  as  in  simple  cases.  The  patient 
ought  to  be  chloroformed,  particularly  in  private  prac- 
tice, where  the  assistance  is  less  efficient  than  in  a 
hospital,  for  though  the  operation  is  rapid  it  is  also 
very  painful.  The  patient  may  struggle  after  one  or 
two  applications  of  the  cautery,  and  even  refuse  to 
allow  others  to  be  made,  so  that  the  operation  would 
remain  incomplete.  The  orifice  of  the  anus  and  the 
surrounding  parts  must  be  painted  with  collodion.  This 
is  a very  important  precaution.  All  surgeons  have 
affirmed  the  difficulty  of  preventing  the  effects  of  ra- 
diated heat.  To  preserve  the  parts  from  these  effects, 
cloths  steeped  in  cold  water,  and  thin  plates  of  wood, 
have  been  used ; but  not  only  are  these  in  the  opera- 
tor’s way,  but  they  are,  as  a rule,  inefficacious. 
Collodion,  on  the  contrary,  even  when  applied  in  a 
thin  layer  only,  forms  an  artificial  epidermis  scarcely 
permeable  to  heat  and  sufficiently  protecting  the  skin. 

“ It  is  necessary  to  dissipate  the  ether-vapour,  or  it 


OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS  123 

would  take  fire  as  soon  as  the  heated  cauteriser  is 
brought  near  the  anus.  The  accident  would  not  be  of 
much  importance,  for  the  burning  vapour  is  easily 
extinguished  by  blowing  it  out ; but  it  is  better  to 
avoid  it  altogether.  It  is  easy  to  understand  the  im- 
portance of  the  use  of  collodion  in  relation  to  the  pain 
which  succeeds  the  operation.  The  patient  cannot 
feel  pain  in  the  parts  to  which  the  iron  has  been 
applied,  for  the  tissues  are  dead,  but  he  suffers  in  the 
surrounding  parts  which  have  been  attacked  by  the 
radiated  heat,  and  the  painful  nature  of  superficial 
burns  is  well  known.  The  burns,  however,  are  not 
very  serious,  and  the  pain  lasts  only  about  four  days, 
being  principally  felt  at  the  time  when  the  inflammation 
necessary  for  the  falling  off  of  the  sloughs  develops 
itself,  or  during  defaecation  after  the  sloughs  have  fallen 
off.  The  cauterisers  ought  to  be  knife-shaped,  or  even 
with  round  points.  To  ensure  the  rapidity  of  the 
operation  they  should  be  heated  to  white  heat.  One 
operation  is  frequently  enough,  but  more  than  two  are 
never  necessary,  how  large  soever  the.  haemorrhoidal 
tumour  may  be,  for  we  do  not  act  directly  on  the  latter, 
but  on  the  anus. 

<c  In  some  cases  the  tumour  cannot  be  reduced  before 
operation,  or  can  be  only  partially  replaced,  the  in- 
voluntary contractions  of  the  muscles  causing  it  again 
to  protrude.  No  notice  need  be  taken  of  this  accident. 
The  cauteriser  is  slipped  between  the  tumour  and  the 
walls  of  the  anus,  for  it  is  of  little  consequence  if  the 
haemorrhoids  should  be  lightly  cauterised  by  the  back 
of  the  instrument. 

“ Sometimes  the  shoulder  of  the  cauteriser  implicates 
the  cutaneous  circumference  of  the  anus,  but  that  is  of 


124  OPERATIONS  UPON  INTERNAL  HEMORRHOIDS 


no  importance ; it  is  even  sometimes  useful  when  the 
anus  is  considerably  relaxed.  There  is  no  need  to 
dread  haemorrhage,  for  the  cauteriser  interferes  only 
with  the  mucous  membrane,  the  submucous  cellular 
tissue  at  the  entrance  of  the  anus,  and  the  skin  at  the 
edge  of  the  orifice.  At  all  these  points  the  vessels  are 
small,  and  when  the  hsemorrhoidal  tumour  is  touched 
by  the  back  of  the  cauteriser,  it  is  in  so  light  a manner 
that  no  vessel  of  any  magnitude  can  be  opened. 

“ If  any  accident  is  to  be  feared  it  would  be  stric- 
ture of  the  rectum  ; but  the  four  cicatrices  which  have 
been  formed  at  the  entrance  of  the  anus,  although 
possessed  of  great  retractile  power,  are  made  linear  and 
in  the  direction  of  the  intestine.  Between  them  are 
intervals  occupied  by  highly  elastic  tissue,  and  the 
presence  of  these  renders  stricture  impossible.  It  may 
be  objected  that,  if  the  anus  remain  sufficiently  dilatable, 
the  patient  may  have  a relapse.  This  accident  is 
certainly  not  impossible,  but  it  is  the  business  of  the 
surgeon  to  estimate  the  state  in  which  he  finds  his 
patient.  If  he  be  going  to  operate  upon  an  old  person 
having  a large  and  old-standing  tumour,  and  whose 
anus  has  little  resilient  power,  he  should  lean  a little 
more  heavily  on  the  cauteriser,  so  as  to  implicate  a 
greater  thickness  of  tissue  than  in  ordinary  cases  ; by 
this  procedure  he  will  be  sure  to  avoid  a relapse.” 

I will  only  remark  that  I have  no  doubt  the  opera- 
tion is  efficient.  The  recovery  is  rather  long  and  the 
pain  is  considerable,  but  by  experiment  I find  that  the 
application  of  collodion  does  away  in  great  degree 
with  the  pain  usually  inflicted  by  radiation  of  heat. 


OPERATIONS  UPON  INTERNAL  HEMORRHOIDS  125 


VII.  Operation  by  the  galvanic  cautery 

The  galvanic  cautery  may  be  employed  for  the 
removal  of  haemorrhoids,  the  division  of  fistula,  and 
other  surgical  operations  about  the  rectum.  I have 
myself  some  personal  experience  in  its  use.  I fail, 
however,  to  see  any  good  reason  for  the  adoption  of 
this  method  of  operating  in  ordinary  cases.  If  a 
cautery  be  required,  I cannot  tell  why  the  galvanically 
heated  wire  should  be  preferable  to  an  iron  heated  in 
the  fire,  or  to  any  form  of  platinum  cautery  rendered 
hot  by  the  rapid  combustion  of  benzoline,  as  in  the 
“ Paquelin 55  instrument.  In  my  humble  opinion  in 
almost  all  cases  the  “ Paquelin  cautery  ” is  superior  to 
any  other.  As  a matter  of  course,  the  person  working 
the  cautery  must  thoroughly  understand  the  mechanism 
of  the  instrument,  and  have  had  some  practice  in  its 
use.  All  the  failures  I have  seen  with  it  have  been 
consequent  upon  the  small  knowledge  of  those  who 
were  working  it.  An  expert  can  at  an  instant  give 
any  heat  you  may  require  from  white  to  black. 

The  galvanic  cautery  requires  a cumbersome  bat- 
tery ; it  is  exceedingly  apt  to  fail ; you  may  at  the 
supreme  moment  get  either  too  much  or  too  little  heat, 
and  this  difficulty  will  occur  even  in  the  hands  of  a 
specially  trained  assistant.  There  is  still  another 
objection,  which  applies  chiefly  to  simple  cases,  as,  for 
example,  the  removal  of  piles ; there  seems  an  amount 
of  fuss  and  pseudo-scientific  show  about  it  to  which  my 
mind  is  exceedingly  repugnant.  The  only  battery  at 
all  reliable  is  Daniell’s. 


126  OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS 


VIII.  The  removal  of  haemorrhoids  by  the  clamp  and 
scissors , the  bleeding  being  arrested  by  the  applica- 
tion of  the  heated  iron 

This  operation  is  generally  known  as  the  “ clamp 
and  cautery  ” operation,  and  is  now  most  frequently 
associated  with  the  name  of  Mr  Henry  Smith,  although, 
in  truth,  it  was  devised  in  its  entirety  by  Mr  Cusack, 
of  Dublin,  and  was  first  introduced  into  London  by 
Mr  Henry  Lee,  of  St  George’s  Hospital.  In  its  per- 
formance each  pile  is  seized  by  a vulsellum  and  drawn 
well  down,  the  clamp  is  then  applied  so  as  to  embrace 
its  base,  the  portion  above  the  clamp  is  cut  off  with  a 
pair  of  scissors  curved  on  the  flat,  and  a cautery  iron 
heated  to  a dull  red  heat  is  freely  applied  to  the  stump 
until  all  the  vessels  are  well  seared. 

In  my  opinion,  this  operation  has  little  to  recom- 
mend it.  As  regards  danger  to  life — after  all  the 
issue  of  the  greatest  moment — as  far  as  my  most  care- 
ful researches  have  led  me  to  a conclusion,  it  is  quite 
six  times  as  fatal  as  the  ligature  properly  and  dexter- 
ously applied. 

Mr  Henry  Smith,  in  the  c Lancet 9 of  April  20th, 
] 878,  has  published  his  last  series  of  cases,  numbering 
530  in  all;  be  acknowledges  4 deaths.  In  195  cases 
operated  upon  by  me  by  means  of  clamp  or  cautery,  I 
have  had  2 deaths.  This  result  is  the  more  to  be 
regretted,  seeing  that  in  1600  cases  of  ligature  com- 
bined with  incision  I have  not  had  a single  death  from 
any  cause  whatever. 


To  face  p.  126 


Fig.  5. 

Mr.  Allingham’s  Clamp  for  Haemorrhoids. 


OPERATIONS  UPON  INTERNAL  HEMORRHOIDS  127 


IX.  Dilatation  of  the  sphincter  muscles 

The  treatment  of  hsemorrhoids  by  the  complete 
dilatation  of  the  external  and  internal  sphincter  mus- 
cles has  been  strongly  advocated  in  France  by  many 
eminent  surgeons,  and  notably  by  Yerneuil,  Fontan, 
Panas,  Gosselin,  Monod,  and  others. 

The  benefits  resulting  from  dilatation  seem  to  have 
been  accidentally  discovered,  and  I cannot  admit  that 
the  rectal  physiology  of  Yerneuil  gave  by  any  means 
the  clue  to  this  treatment.  For  my  justification  for 
this  statement  I must  refer  my  readers  to  p.  86  of  this 
work. 

I have  now  no  doubt  that  in  certain  cases  of 
haemorrhoids  dilatation,  full  but  gentle,  of  both 
sphincter  muscles  will  give  wonderful  relief,  and  I 
have  myself  in  many  cases  seen  great  good  accrue ; 
but,  on  the  other  hand,  there  are  cases  in  which  no 
good  has  resulted,  and  reflection  would  lead  one  to 
conceive  that  such  would  almost  certainly  be  the  case. 

When,  for  example,  in  old- standing  disease  the 
haemorrhoids  easily  prolapse  at  stool,  and  on  walking, 
stooping,  coughing,  and  other  common  physical  acts, 
the  sphincter  muscles  become  so  dilated  that  more 
dilatation  could  not  possibly  mend  matters.  For  here 
no  strangulation  or  pressure  takes  place;  the  piles 
themselves  are  large,  but  they  do  not  swell  and  be- 
come livid  when  outside  the  body,  and  the  discomfort 
and  suffering  result  not  from  any  “ pinching,5 5 but 
from  the  exposure  of  mucous  membrane  to  accidental 
friction  or  injury,  and  from  the  mucous  and  muco- 
sanguineous  discharge,  and  I have  often  seen  such 


‘128  OPERATIONS  UPON  INTERNAL  HEMORRHOIDS 

cases  where  no  remnant  even  of  the  sphincter  muscles 
could  be  detected;  and  when  the  haemorrhoids  were 
returned  a large  patulous  opening  could  be  seen,  into 
which  the  hand  might  easily  be  passed.  To  cure  these 
patients  it  is  necessary  not  only  to  remove  the  growths, 
but  often  also  to  obtain  contraction  of  the  anal  orifice 
by  applying  freely  the  hot  iron,  so  as  to  produce  several 
linear  cauterisations,  after  Woillemier’s  plan. 

The  cases  best  suited  to  dilatation  are  the  very  oppo- 
site to  those  just  described.  When  the  piles  protrude 
they  are  tightly  embraced  by  the  sphincter  muscles, 
and  immediately  become  swollen  and  livid,  and  perhaps 
bleed  freely,  the  patient  being  able  only  with  much 
trouble  and  considerable  pain  to  return  them.  Here  it 
is  manifest  that  dilatation  of  the  sphincters  may  afford 
speedy  relief  and  even  result  in  a cure.  In  such  a case 
the  muscles  around  the  lower  inch  or  so  of  the  rectum 
are,  from  irritation,  in  a state  of  almost  constant  spas- 
modic contraction,  consequently  all  the  vessels  are  en- 
gorged and  the  return  of  blood  from  the  rectum  is 
greatly  impeded,  and  the  haemorrhoids  grow  with  much 
rapidity.  Complete  dilatation  is  to  be  effected  in  the 
following  way  : — The  patient  being  fully  under  the  influ- 
ence of  ether,  you  insert  both  thumbs  into  the  rectum 
and  dilate  gradually,  first  in  the  antero-posterior,  and 
afterwards  in  the  opposite  direction,  using  an  amount 
of  force  sufficient  thoroughly  to  overcome  the  spasm. 
You  continue  to  manipulate  the  sphincters  until  the 
muscles  feel  as  if  reduced  to  a thoroughly  pulpy  con- 
dition ; care  must  be  taken  to  act  high  enough  up  in 
the  rectum  so  as  to  include  the  whole  of  the  sphincter. 
The  result  is  that  the  state  of  contraction  is  abolished 
and  no  spasm  can  occur ; in  fact,  for  the  time,  like  in 


• OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS  129 


any  overstretched  muscle,  paralysis  has  been  induced. 
With  practice  and  great  gentleness  the  desired  result 
may  be  accomplished  without  tearing  the  mucous  mem- 
brane, or  even  drawing  blood,  but  a little  extravasation 
is  usually  noticed  around  the  anus  for  a few  days. 
After  this,  place  an  opium  suppository  in  the  rectum, 
and  keep  your  patient  recumbent  in  bed.  What  takes 
place  ? First,  all  the  blood  returns  freely  to  the  liver, 
no  stasis  remains,  the  piles  diminish  in  size,  the  pain 
passes  away,  and  in  four  or  five  days  your  patient  may 
rise  and  go  about  his  business  wonderfully  relieved. 
If  at  the  end  of  two  or  three  days  you  examine  the 
sphincters,  you  will  find  them  both  capable  of  acting, 
though  gently ; there  is  no  spasm.  When  you  insert 
your  finger  the  muscle  closes  upon  it,  but  does 
not  grasp  it;  the  spasm,  indeed,  which  before  the 
operation  rendered  it  difficult  for  you  to  get  your 
finger  into  the  bowel,  has  gone,  and  with  care  and 
judicious  treatment  may  never  return,  in  which  case 
the  patient  would,  at  all  events  for  a considerable  time, 
be  cured  of  his  haemorrhoids. 

When,  in  addition  to  piles,  a fissure  or  ulcer  exists, 
more  immediate  benefit  is  obtained,  as  great  pain  on 
going  to  stool,  will  no  longer  be  felt,  and  in  the  majority 
of  cases  the  sore  place  will  heal.  In  the  early  condi- 
tions of  haemorrhoids,  when  there  is  little  or  no  pro- 
trusion, and,  as  often  happens,  only  occasional  loss  of 
blood  and  spasm  of  the  sphincter,  the  dilatation  will, 
as  I have  personally  found,  really  cure  the  patient,  or 
at  all  events  postpone  for  an  indefinite  time  the  growth 
of  the  haemorrhoids.  In  the  case  of  a gentleman, 
recently  under  my  care,  painful  internal  haemorrhoids 
existed  as  a complication  of  cancer  of  the  rectum. 

9 


130  OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS 

Careful  dilatation  cured  the  haemorrhoids  and  made  him 
comparatively  comfortable. 

In  properly  selected  cases  I am  of  opinion  that  dila- 
tation is  really  an  admirable  method  of  treatment, 
devoid,  as  it  is,  of  danger,  causing  only  trifling  pain, 
and  not  keeping  the  patient  in  bed  more  than  a very 
few  days. 

The  treatment  of  internal  hcemorrhoids  by  crushing 

In  the  c Lancet’  of  July  3rd,  1880,  Mr  George  Pollock, 
of  St  George’s  Hospital,  advocates  treatment  by  crush- 
ing. He  says,  “ It  is  now  some  two  or  three  years  since 
I commenced  to  put  into  practice  my  views  as  to 
crushing.  The  earlier  attempts  to  crush  the  base  of 
the  pile  were  partial  failures  as  regarded  the  perfect 
freedom  from  hsemorrhage.  From  want  of  proper 
construction  the  clamp  did  not  effectually  spoil  the 
tissues  at  the  base  of  the  piles,  seldom,  however,  were 
more  than  two  or  three  ligatures  necessary,  and  there 
never  was  troublesome  or  recurring  haemorrhage  en- 
countered.” Mr  Pollock  proceeds  to  state  that  the 
subsequent  pain  is  much  less  than  that  which  usually 
follows  the  use  either  of  the  ligature  or  of  the  clamp 
and  cautery,  and  he  recommends  the  crushing  pincers 
designed  by  Mr  Benham.  A plan  of  treatment  recom  - 
mended by  such  a sound  surgeon  as  Mr  Pollock  I 
could  not  but  consider  worthy  of  a fair  and  extended 
trial,  and  I at  once  procured  Mr  Benham’s  crusher 
from  Messrs  Wright,  of  New  Bond  Street,  and  imme- 
diately commenced  to  operate,  following  strictly  Mr 
Pollock’s  directions.  After  operating  on  about  ten 
cases  at  St  Mark’s  Hospital,  I came  to  the  conclu- 


To  face  p.  131 


Screw-crushing  Instrument. 
Fig.  6. 


One-third  full  size. 


The  crusher  is  made  of  solid  steel,  forming  an  open  square  at  one 
end,  between  the  sides  of  which  a second  piece  of  steel  slides  up 
and  down.  This  bar  is  connected  with  the  screw,  which  brings  it 
firmly  home  against  the  distal  end  of  the  square,  first  by  sliding  and 
then  by  screw-action,  and  exerts  great  crushing  power  upon  any  tissues 
which  are  brought  between  the  two  opposing  surfaces.  To  enable  the 
instrument  to  be  cleaned  the  handle  can  be  opened  by  pressing  the 
ends  of  the  levers  A A.  After  use  the  instrument  should  be  cleaned, 
dried,  and  oiled  to  ensure  its  easy  working. 


Fig.  7. 


Fig.  7 represents  the  spring  forceps  used  in  bringing  into  the  clamp 
the  portion  of  pile  to  be  removed. 


OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS  131 

sion  that  even  Mr  Benham’s  instrument  did  not  suffi- 
ciently crush  the  base  of  the  pile,  and  that  more  or 
less  haemorrhage  nearly  always  resulted.  In  one 
bad  case  concealed  bleeding  took  place  ( i . e.  haemor- 
rhage into  the  bowel  without  any  escape  from  the 
anus).  Some  hours  after  the  operation  the  patient  said 
he  must  go  to  stool  and  he  evacuated  a large  quantity 
of  arterial  blood,  and  this  haemorrhage  continued  until 
the  clots  were  got  rid  of  by  injection  of  cold  water, 
and  plugging  the  rectum  with  wool  and  perchloride  of 
iron  was  resorted  to  by  the  house-surgeon.  I had  the 
pleasure  of  consulting  Mr  Benham  with  regard  to  his 
invention,  and  he  suggested  a modified  form  with  which 
he  saw  me  operate  on  several  cases ; still,  however,  the 
crusher  did  not  on  all  occasions  perfectly  arrest  haemor- 
rhage, although  I kept  it  applied  in  bad  cases  for  two 
minutes.  My  son,  Mr  Herbert  W.  Allingham,  then 
devised  a new  form  of  crusher,  in  which  a screw-move- 
ment was  substituted  for  the  lever-action  in  Mr 
Benham’s  instrument.  We  then  had  an  instrument 
capable  of  exercising  an  almost  unlimited  amount  of 
crushing  power  (see  the  woodcut).  It  was  constructed 
by  Messrs  Krohne  and  Sesemann,  and  a good  many 
were  made  before  anything  like  perfection  was  at- 
tained, but  now  I believe  that  the  screw-crusher  is  a 
very  safe  instrument,  provided  that  due  care  be  taken 
in  operating. 

A few  words  about  the  method  of  using  the  crusher. 
As  above  stated,  in  my  first  dozen  or  more  cases 
I followed  rigidly  Mr  Pollock’s  directions,  but  after- 
wards I thought  it  better  to  avoid  crushing  skin, 
and  therefore  made  an  incision  where  the  mucous  mem- 
brane joins  the  skin.  I also  commenced  the  operation 


132  OPERATIONS  TJPON  INTERNAL  HAEMORRHOIDS 

by  gently  but  fully  dilating  tbe  sphincters — a plan  I 
always  adopt  when  applying  a ligature  to  internal  piles. 
The  haemorrhoid  is  drawn  into  the  screw-crusher  by 
means  of  a vulsellum  or  hook,  and  this  being  entrusted 
to  an  assistant,  the  screw  is  pushed  up  and  screwed 
home  as  tightly  as  thought  desirable.  The  projecting 
portion  of  the  pile  is  cut  off  with  the  knife  or  scissors, 
and  the  pressure  may  be  kept  up  as  long  as  the  opera- 
tor thinks  fit ; I now  keep  the  instrument  applied  for 
about  twenty-five  seconds  only.  In  this  operation  care 
must  be  taken  not  to  remove  too  much  tissue.  If  this 
precaution  be  not  attended  to,  some  amount  of  uncom- 
fortable contraction  is  sure  to  take  place.  This,  in  my 
experience,  is  one  drawback  to  Mr  Benliands  clamp  ; 
the  instrument  is  large  and  difficult  of  adjustment, 
consequently  more  tissue  may  be  taken  away  than  the 
operator  is  aware  of. 

I have  now  (1881)  operated  upon  72  patients,  37  at 
St  Mark’s  Hospital,  and  the  remainder  in  private  prac- 
tice. I shall  continue  to  employ  the  crushing  method 
in  selected  cases,  as  I am  by  no  means  convinced  of 
its  universal  applicability  or  advantage.  As  regards 
freedom  from  pain,  I have  been  on  the  whole  disap- 
pointed ; in  some  cases  there  was  but  little  suffering 
directly  after  the  operation,  but  great  pain  followed 
every  action  of  the  bowels  for  some  time.  In  others 
the  immediate  pain  was  quite  as  severe  and  prolonged 
as  that  caused  by  the  ligature.  (Edema  of  the  external 
parts,  when  many  or  large  piles  were  removed,  was 
very  marked  in  nearly  all  my  cases ; often  the  external 
swelling  did  not  show  itself  until  after  the  first 
action  of  the  bowels.  I cannot  say  that  the  patients 
recover  very  rapidly;  my  average  at  St  Mark’s  in 


OPERATIONS  UPON  INTERNAL  HEMORRHOIDS  133 

37  cases  was  twenty-three  days,  and  in  35  private 
patients  the  average  was  twenty  days.  Contraction,  so 
as  to  require  the  use  of  bougies  or  dilatation  by  the 
finger,  occurred,  on  an  average,  once  in  every  9 
cases.  As  to  haemorrhage,  when  Mr  Benham’s  clamp 
was  used,  ligatures  were  necessary  in  nearly  all  severe 
cases,  and  in  two  the  bleeding  was  so  free  a few 
hours  after  the  operation  as  to  necessitate  plugging 
the  rectum  with  a tube.  I cannot  say  that  with  the 
screw-crusher  bleeding  has  never  occurred,  but  it  has 
not  done  so  to  any  extent,  and  ligature  of  a vessel 
has  rarely  been  required,  torsion  usually  sufficing.  On 
the  whole,  in  my  opinion,  crushing  is  a satisfactory 
method  of  removing  internal  piles,  and  is  in  every 
respect  superior  to  the  clamp  and  cautery.  I am 
inclined  to  consider  it  a safe  operation,  but  on  that 
point  no  definite  conclusion  can  yet  be  formed.  That 
the  operation  as  regards  safety  to  life,  freedom  from 
haemorrhage,  pain,  and  troublesome  complications,  is 
vastly  superior  to  the  ligature  skilfully  applied  has  yet 
to  be  proved,  and  cannot  be  admitted  until  many 
hundreds  of  operations  have  been  recorded. 

The  treatment  of  internal  haemorrhoids  by  ligature 

In  expressing,  as  I most  unreservedly  do,  the 
opinion  that  the  ligature  is  the  safest,  easiest,  and 
best  operation  for  the  great  majority  of  cases  of 
haemorrhoids,  I must  be  understood  to  mean  the  ope- 
ration usually  performed  at  St  Mark’s  Hospital,  viz. 
ligature  combined  with  incision.  The  operation  was 
devised  by  the  late  Mr  Salmon,  and  has  been  prac- 
tised at  that  institution  for  more  than  forty  years.  I 


134  OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS 

must  premise  that  in  all  operations  about  the  rectum, 
but  more  particularly  in  cases  of  piles,  it  is  essential 
that  the  alimentary  canal  should  be  thoroughly  cleared 
of  its  contents.  For  two  or  three  days  prior  to  the 
operation  some  mild  but  efficient  purgative  should  be 
taken,  and  it  is  well,  if  possible,  to  have  an  enema  of 
warm  water  administered  a few  hours  before  operating. 

In  cases  of  piles  I prefer  the  patient  to  lie  on  the 
right  side  on  a hard  couch,  with  the  back  towards  the 
light,  and  the  knees  drawn  well  up  to  the  abdomen. 
The  assistant  should  stand  with  his  back  towards  the 
patient’s  head  and  raise  the  upper  buttock  with  the 
right  hand,  the  right  elbow  being  at  the  same  time 
hooked  over  the  pelvis  so  that  he  can  control  move- 
ment on  the  part  of  the  patient  and  keep  him  in  a 
good  position.  The  patient  being  thus  prepared  and 
fully  under  the  influence  of  the  anesthetic,  I now 
always  gently,  but  completely,  dilate  the  sphincter 
muscles;  this  completed,  the  rectum  for  three  inches 
is  within  your  easy  reach,  and  no  contraction  of  the 
sphincters  takes  place,  so  that  all  is  clear  like  a map 
before  you.  The  hasmorrhoids,  one  by  one,  are  to  be 
taken  by  the  surgeon  with  a vulsellum  or  pronged 
hook-fork  and  drawn  down ; he  then  with  a pair  of 
sharp,  strong,  spring  scissors  separates  the  pile  from  its 
connection  with  the  muscular  and  submucous  tissues 
upon  which  it  rests ; the  cut  is  to  be  made  in  the 
sulcus  or  white  mark  which  is  seen  where  the  skin 
meets  the  mucous  membrane,  and  this  incision  is  to  be 
carried  up  the  bowel,  and  parallel  to  it,  to  such  a dis- 
tance that  the  pile  is  left,  connected  by  an  isthmus  of 
vessels  and  mucous  membrane  only . 

There  is  no  danger  in  making  this  incision,  because 


OPERATIONS  UPON  INTERNAL  HEMORRHOIDS  135 

all  the  larger  vessels  come  from  above,  running  parallel 
with  the  bowel,  just  beneath  the  mucous  membrane , 
and  thus  enter  the  upper  'part  of  the  pile.  A well- 
waxed,  strong,  thin,  plaited  silk  ligature  is  now  to  be 
placed  at  the  bottom  of  the  deep  groove  you  have 
made,  and  the  assistant  then  drawing  out  the  pile 
with  some  decision,  the  ligature  is  tied  high  up  at  the 
neck  of  the  tumour  as  tightly  as  possible.  Be  very 
careful  to  tie  the  ligature,  and  equally  careful  to  tie  the 
second  knot,  so  that  no  slipping  or  giving  way  can 
take  place.  I myself  always  tie  a third  knot ; the 
secret  of  the  well-being  of  your  patient  depends  greatly 
upon  this  tying — a part  of  the  operation  by  no  means 
easy,  as  all  practical  men  know,  to  effect.  If  this  be 
done,  all  the  vessels  must  be  included.  The  silk  should 
be  so  strong  that  you  cannot  break  it  by  fair  pulling. 
If  the  pile  be  very  large  a small  portion  may  now  be 
cut  off,  taking  care  to  leave  sufficient  stump  beyond  the 
ligature  to  guard  against  its  slipping.  When  all  the 
haemorrhoids  are  thus  tied,  they  should  be  returned 
within  the  sphincter  ; after  this  is  done,  any  super- 
abundant skin  which  remains  apparent  may  be  cut  off  ; 
but  this  should  not  be  too  freely  excised  for  fear  of 
contraction  when  the  wounds  heal.  An  injection  of 
Liq.  Opii  Sedativus  may  be  administered,  or  a sup- 
pository of  half  a grain  of  morphia  made  with  gelatine 
and  glycerine.  I always  place  a pad  of  wool  over  the 
anus,  and  a tight  f -bandage,  as  it  relieves  pain  most 
materially  and  prevents  any  tendency  to  straining. 

It  is  advisable  to  commence  operating  upon  those 
piles  that  are  situated  interiorly,  as  the  patient  lies,  in 
order  that  the  others  may  not  be  obscured  by  blood, 
but  when  the  haemorrhoids  are  numerous,  and  there  is 


136  OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS 


a small  pile  either  anterior  or  dorsal,  as  is  frequently 
the  case,  it  is  better  to  tie  the  small  ones  first,  as  there 
is  danger  of  their  being  overlooked,  and  if  they  are  left 
they  are  likely  to  grow,  and  a return  of  the  piles  may 
be  confidently  anticipated  in  a few  months.  I have  seen 
many  cases  in  which  this  has  occurred. 

When  the  patient  takes  an  anaesthetic  it  sometimes 
happens  that  the  protruded  piles  slip  up  into  the 
bowel  again.  I have  seen  inexperienced  operators 
much  worried  by  this,  but  you  need  give  yourself  no 
anxiety  about  it ; when  the  patient  is  fully  narcotised 
carefully  dilate  the  sphincters  as  I have  before  recom- 
mended. The  advantages  are  that  the  whole  rectum  is 
fully  exposed  and  even  every  abrasion  can  be  seen, 
and,  secondly,  the  spasmodic  pain  after  the  operation, 
by  this  dilatation,  is  almost  entirely  done  away  with. 

Spasm  of  the  sphincter  muscle  is  in  a great  degree 
the  cause  of  pain  and  its  long  continuance — my  patients 
now  never  have  pain  after  about  three,  or  at  most 
four  hours.  The  only  suffering  that  may  remain  is 
caused  by  spasm  of  the  levator  ani,  which  will  act  from 
time  to  time,  and  a retraction  of  the  anus  into  the 
rectum  takes  place,  attended  with  momentary  darting 
pain.  I was  never  certain  why  it  was  that  patients 
who  had  suffered  long  from  large  protruding  piles, 
which  they  could  not  keep  up,  scarcely  experienced  any 
pain  after  ligature ; now  I know  that  the  sphincter 
muscles  caused  most  of  the  pain,  and  those  who  had 
practically  no  sphincters  did  not  have  a tithe  of  the 
pain  the  person  with  a strong  sphincter  had. 

After  the  operation  the  bowels  should  be  confined 
for  three  or  even  four  days.  I find  a solid  one-grain 
opium  pill  given  half  an  hour  after  the  operation, 


OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS  137 

and  repeated  every  two  hours  twice,  the  best  to  begin 
with ; the  pill  arrests  or  prevents  vomiting ; later  on,  if 
required,  a draught  may  be  administered.  The  formula 
I often  use  is  the  following : — Pul  vis  Oretae  Aromat.  3j ; 
Tinct.  Opii  or  Liq.  Opii  Sedativus  tnxv ; Spt.  iEther. 
Nit.  sj  ; Mist.  Camphors©  ad  3iss.  To  be  taken  night 
and  morning,  or  three  times  in  the  day  for  two  days. 
In  very  bad  cases  and  in  delicate  persons  I occasionally 
keep  the  bowels  quiet  for  a much  longer  period  than 
four  days.  I have  done  so  for  a week  or  ten  days,  and 
I think,  in  some  instances,  with  very  manifest  advan- 
tage. The  diet  at  first  should  be  light : soup,  beef  tea, 
a little  boiled  fish,  milk  gruel,  tea  and  toast,  will  be 
quite  sufficient ; no  alcohol  at  all  should  be  taken  ; per- 
fect rest  in  the  recumbent  position  enjoined.  On  the 
third  or  fourth  night,  according  to  the  state  of  the 
patient,  a mild  aperient  may  be  administered,  and  fol- 
lowed by  a draught  or  a carefully  administered  enema  of 
warm  gruel  in  the  morning,  and  after  it  has  acted  a more 
liberal  diet  may  be  allowed,  but  I always  advise  absti- 
nence from  wine,  beer,  or  spirits,  unless  there  be  some 
special  condition  indicating  the  necessity  for  their  use. 

It  is  well  to  tell  your  patient  that  some  temporary, 
and  possibly  rather  acute,  pain  may  be  experienced  on 
the  first  action  of  the  bowels,  and  also  that  a slight 
discharge  of  blood  may  take  place  (it  by  no  means 
always  occurs) ; if  you  neglect  this,  needless  alarm  is 
often  created,  the  patient  imagining  if  he  sees  any 
blood,  or  has  much  pain,  that  all  his  old  trouble  has 
returned. 

I think  it  advisable,  though  not  absolutely  necessary, 
that  the  patient  should  keep  lying  down  until  the  liga- 
tures separate,  which  process  almost  invariably  takes 


138  OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS 

place  about  the  sixth  or  seventh  day,  occasionally  a day 
sooner,  very  rarely  a day  later.  If  the  ligatures  are 
tied  tightly  and  the  incision  has  been  free,  this  course 
of  events  is  but  very  seldom  departed  from.  I have 
been  in  the  habit  for  a long  time  of  giving  daily  a gentle 
pull  at  the  ligatures,  commencing  the  day  after  the 
bowels  are  first  relieved;  by  this  plan  the  ligatures 
always  separate  on  the  fifth  or  sixth  day.  Active 
exertion , even  after  the  separation  of  the  ligatures,  is 
to  be  deprecated  until  the  sores  left  in  the  rectum  are 
healed ; a fortnight  or  a little  longer  is  generally  about 
the  time  required  to  accomplish  this.  It  is  quite 
unnecessary  that  the  patient  should  be  kept  in  bed  all 
this  time,  or  even  to  his  chamber — he  may  move  about 
in  moderation ; but  I am  certain  that  a too  speedy 
resumption  of  the  erect  position  is  likely  to  retard  the 
cicatrization  of  the  wounds.  The  patient  is  convales- 
cent, but  not  quite  well. 

I have  had  patients  who  have  gone  about  their 
business  with  ligatures  on  their  haemorrhoids,  and  have 
sustained  no  injury ; here  is  a case  of  that  kind.  A 
gentleman  on  the  Stock  Exchange  was  operated  on  by 
me  some  years  ago ; it  was  rather  more  than  an  ave- 
rage case ; five  ligatures  were  applied.  On  the  day 
following  the  operation  some  sudden  turn  of  the  mar- 
kets rendered  it  absolutely  necessary  for  him  to  go  to 
town.  When  I called  upon  him,  to  my  surprise  I 
found  that  he  had  left  home;  and  for  three  days 
consecutively  he  went  to  his  office  and  remained  there 
for  five  hours  transacting  his  business,  as  he  afterwards 
assured  me,  with  very  much  less  inconvenience  than 
he  had  frequently  experienced  before  the  operation, 
when  the  piles  came  down.  He  was,  in  the  end,  none 


OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS  139 

the  worse  for  his  temerity,  but  it  is  an  example  by  no 
means  to  be  commended  or  followed.  On  another 
occasion  a naval  officer  found  himself  compelled  to  go 
on  board  his  ship  on  the  third  day  after  operation, 
journeying  to  Portsmouth  for  the  purpose.  This 
gentleman  did  not  suffer  any  serious  inconvenience. 
Mr  Quain  in  his  work  relates  a parallel  case.  It  is 
no  uncommon  thing  for  me  to  have  patients  who  are 
able  to  resume  their  ordinary  occupation  on  the  eighth 
or  ninth  day.  In  a case  sent  me  by  my  friend  Mr 
Williams,  of  Brentford,  who  also  assisted  me  at 
the  operation,  the  haemorrhoids  were  very  large,  and 
four  ligatures  were  applied,  but  there  was  no  super- 
abundant shin  requiring  removal.  On  the  eighth  day 
this  gentleman  was  really  quite  capable  of  walking  a 
distance,  and  was  rather  surprised  that  I requested 
him  to  abstain  from  much  exercise ; he  had  no  pain  or 
any  symptom  to  indicate  that  he  had  not  perfectly 
recovered,  but  I am  sure  it  would  have  been  very 
unwise  of  me  to  allow  him  to  do  as  he  wished. 
The  wounds  inside  the  rectum,  I knew,  could  not  be 
soundly  healed,  and  the  delay  likely  to  be  occasioned 
by  too  much  exertion  or  standing  about  might  be 
serious.  Under  these  circumstances  the  sores  possibly 
would  not  heal,  and  painful  and  troublesome  ulceration, 
very  difficult  of  cure,  might  be  the  result.  For  years  I 
have  digitally  examined  all  my  patients  upon  the  thir- 
teenth or  fourteenth  day  after  the  operation,  and  in  the 
great  majority  I have  not  found  the  rectum  perfectly 
sound ; constantly  some  unhealed  sore  remains,  and  in 
my  opinion  such  a patient  cannot  be  said  to  be  well 
and  allowed  to  go  about  his  ordinary  avocations,  without 
incurring  considerable  danger.  The  veins  of  the  rec- 


140  OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS 


turn  are  destitute  of  valves  and  only  badly  supported 
by  areolar  tissue ; these  sores,  therefore,  much  resemble 
in  their  conditions  varicose  ulcers  of  the  legs ; and  we 
well  know  in  such  cases  rest  in  the  horizontal  position 
is  absolutely  necessary  to  ensure  a speedy  and  certain 
cicatrization.  When,  from  a low  condition  of  health, 
wounds  in  the  rectum  are  long  in  healing,  ulceration 
will  in  all  probability  take  place,  with  contraction  as 
an  almost  certain  result. 

Pain  after  the  operation  varies  according  to  the 
constitution  and  nervous  sensitiveness  of  the  patient, 
and  also  as  to  the  condition  of  the  parts  before  the 
operation ; but,  as  I have  said,  by  performing  gentle  and 
full  dilatation,  pain  is  almost  done  away  with.  Lately 
I had  three  cases  of  hsemorrhoids  consecutively  with 
my  friend. Mr  Aikin,  and  really  these  patients  scarcely 
complained,  though  they  were  sensitive  persons  who,  I 
am  sure,  would  have  had  great  suffering  under  any 
other  method  of  operating.  The  rapidity  of  the  cure  in 
these  three  cases  was  very  remarkable ; one  gentleman, 
more  than  sixty  years  of  age,  and  whose  skin,  from 
great  losses  of  blood,  had  become  quite  the  colour  of 
old  wax,  was  well  in  a fortnight,  the  wounds  being 
perfectly  healed.  Still  more  recently  a gentleman, 
aged  sixty-four,  who  was  seen  by  me  with  Mr  Leggatt, 
positively  never  lost  an  hour’s  sleep,  and  averred  he 
had  do  pain,  and  in  twelve  days  was  fit  for  anything; 
was  not  merely  convalescent,  but  all  the  wounds 
had  healed.  If  pain  should  be  acute  at  first,  push  your 
opium  or  hypodermic  injection  (Morph,  gr.  J,  Atropine 
gr.  is  my  favourite  formula).  A sponge  wrung  out 
of  very  hot  water  and  applied  to  the  sacrum  nearly 
always  affords  relief,  and  however  sharp  the  pain  may 


OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS  141 

be  at  first  (it  is  always  exaggerated  by  tbe  want  of 
moral  control,  brought  about  by  the  inhalation  of 
ether),  in  two  or  three  hours  it  will  have  subsided,  and 
you  may  comfort  your  patient  by  the  assurance  that  the 
worst  of  his  troubles  will  soon  be  oyer,  and  the  pain 
will  most  surely,  if  gradually,  become  less.  After  the 
ligatures  come  away,  I always  direct  my  patients  to 
douche  the  anus  well  night  and  morning  with  cold 
water ; this  is  very  comforting,  and  materially  hastens 
the  convalescence. 

Every  nowand  then  you  may  have  retention  of  urine 
follow  the  operation ; in  most  cases  a warm  hip-bath 
will  enable  the  patient  to  pass  water  in  the  morning ; 
if  not,  of  course  a catheter  must  be  introduced.  Strain- 
ing to  micturate  should  be  avoided  under  any  circum- 
stances. This  retention  is  by  no  means  very  uncom- 
mon in  women,  but  I have  found  it  occur  much  oftener 
in  men.  It  may  be  accounted  for  by  the  fact  that 
the  male  urethra  is  so  much  more  liable  to  stricture 
than  the  female,  and  very  slight  irritation  will  set 
up  spasm  of  the  strictured  part  sufficient  to  induce 
retention.  After  a few  days  the  power  to  pass  water 
will  return ; but  I have  seen  retention  for  ten  days 
or  a fortnight. 

It  sometimes  happens  that  after  a severe  operation 
upon  internal  haemorrhoids,  contraction  takes  place  in 
the  ‘bowel  on  the  healing  of  the  wounds.  This  con- 
traction is  not  usually  at  the  anus,  nor  does  it  affect 
the  skin,  but  mucous  membrane  only ; time  alone  will 
generally  remove  it,  but  as  it  may  occasion  straining 
and  distress  to  the  patient,  I advise  the  passing  of  a 
bougie  for  a few  nights,  or  what  answers  as  well,  and 
is  less  alarming,  I direct  the  introduction  of  the  fore- 


142  OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS 

finger,  well  anointed,  into  tlie  bowel  night  and  morning. 
In  rare  cases,  when  the  wounds  have  been  long  in 
healing,  and  also  if  a great  deal  of  the  bowel  has  been 
removed  longitudinally,  a tight  hour-glass  contraction 
takes  place — usually  the  contracted  part  is  ulcerated 
— the  patient  suffers  much  pain,  has  obstinate  con- 
stipation, and  cannot  sit  up  without  a sensation  of 
bearing  down  and  great  discomfort.  This  is  the  form 
of  stricture  and  ulceration  which  I have  so  frequently 
found  following  operations  when  heated  irons  are 
applied.  I very  often  see  this  result  in  the  practice 
of  others,  and  have  had  it  occur  in  my  own  cases. 
To  get  them  well  requires  great  attention,  gentleness, 
and  perseverance ; usually  constitutional  treatment  is 
required  as  well  as  mechanical ; the  patients  are  nearly 
always  weak  and  unhealthy,  often  strumous,  and  the 
malady  is  more  common  in  women  than  in  men,  and 
the  uterus  therefore  usually  requires  attention.  Sub- 
involution, retro-version,  and  ante-version,  with  flexion 
and  chronic  en do -metritis,  are  the  diseases  frequently 
complicating  the  rectal  mischief,  and  no  surgeon  can 
hope  to  cure  those  patients  who  does  not  take  into 
consideration  the  state  of  the  uterus. 

I do  not  think  in  the  whole  range  of  surgery  there 
is  any  procedure  worthy  of  the  name  “ operation  55 
which  can  show  a greater  amount  of  success  or  smaller 
death-rate  than  the  ligature  of  internal  haemorrhoids. 

In  the  year  1865  I published,  in  the  6 Medical  Times 
and  Gazette,5  some  statistics  of  the  practice  at  St  Mark’s 
Hospital,  which  showed  that,  in  1763  operations  upon 
haemorrhoids,  there  had  been  5 cases  of  tetanus,  4 
occurring  in  the  spring  of  the  year  1858,  2 in  March, 
and  2 in  April.  Since  the  year  1858  about  2250 


OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS  143 


operations  have  been  performed,  and  there  has  not 
been  any  case  of  tetanus ; and  in  these  4013  cases 
there  has  been  but  one  case  of  doubtful  pyaemia.  This 
death  occurred  in  Mr  Gowlland’s  practice.  An  old 
Hebrew  was  operated  on  for  bad  piles  with  the  liga- 
ture. A few  days  after,  diarrhoea  set  in  and  he  died 
exhausted.  Pyaemia  was  suspected,  but  no  necropsy 
was  made,  as  the  Jews  object,  so  there  is  still  an 
element  of  uncertainty  in  the  case.  Since  the  publica- 
tion of  the  last  edition  of  this  work  about  250  cases 
have  been  operated  upon  without  a single  fatal  case  or 
any  symptoms  of  pyaomia  or  tetanus.  The  in-patient 
books  at  St  Mark’s  have  been  excellently  kept,  and 
any  one  interested  in  the  matter  could  easily  satisfy 
himself  that  the  statistics  of  operations  and  deaths 
resulting  are  worthy  of  entire  confidence. 

Let  us  see  how  the  matter  stands.  In  St  Mark’s 
Hospital  the  death-rate  from  all  causes  in  operations 
on  internal  haemorrhoids  by  ligature  during  a space  of 
more  than  forty  years  is  just  1 in  670.  How,  hospital 
practice  is  notoriously  more  fatal  than  private  practice, 
yet  what  a brilliant  result  has  been  obtained  ! Refer- 
ring to  the  four  cases  of  tetanus  occurring  in  St  Mark’s 
in  the  months  of  March  and  April,  1858,  they  must  be 
considered  quite  exceptional,  as  since  that  year  no  case 
of  the  disorder  has  appeared.  Mr  Curling,  in  his 
work  on  6 Diseases  of  the  Rectum,’  says,  “ In  the  year 
1858  tetanus  was  very  rife  in  London.”  I have  the 
good  fortune  not  to  have  had  one  single  fatal  result 
from  the  ligature,  either  in  my  public  or  private  prac- 
tice, which  now  extends  to  more  than  1600  operations. 

Copeland,  in  his  work,  mentions  that  he  had  only 
seen  one  death. 


144  OPERATIONS  UPON  INTERNAL  HAEMORRHOIDS 

Buslie  that  he  never  had  a fatal  case  with  the  ligature. 

Sir  Benjamin  Brodie,  whose  experience  was  un- 
usually large,  states  he  never  lost  a case. 

Mr  Syme  says,  “ In  the  whole  of  my  practice  I 
never  met  with  a case  which  either  terminated  fatally, 
or  even  threatened  to  do  so.” 

Mr  Curling,  in  the  last  edition  of  his  work,  affirms 
“ that,  with  one  exception,  no  fatal  case  of  operation 
by  the  ligature  has  occurred  either  in  my  public  or 
private  practice.” 

Mr  Quain  had  only  one  patient  succumb  in  his  prac- 
tice with  the  ligature. 

Mr  Ashton  has  not  recorded  a single  death  from  his 
method  of  operating  by  ligature. 

My  colleague,  Mr  Gowlland,  who  in  all  probability 
has  had  a larger  experience  in  rectal  surgery  than  any 
other  surgeon  in  London,  has  had  a most  remarkable 
success  with  the  ligature  in  haemorrhoids ; and  after 
a prolonged  trial  with  the  clamp  and  cautery,  has 
finally  abandoned  it. 

My  friend,  Mr  Alfred  Cooper,  with  large  opportu- 
nities for  arriving  at  a correct  judgment,  informs  me 
that  he  has  never  had  a fatal  case  with  the  ligature, 
and  now  does  not  employ  the  cautery.  My  remaining 
colleague,  Mr  Goodsall,  is  also  at  one  with  me  in  pre- 
ferring the  ligature. 

Let  us  for  a moment  see  what  our  American  con- 
freres think : 

Gross,  in  his  great  work  on  surgery,  says  : “ The 
operation  (ligature)  is  as  simple  of  execution  as  it  is 
free  from  danger,  and  certain  in  its  results.” 

Dr  Van  Buren,  so  well  known  here,  and  whose 
experience  in  the  treatment  of  rectal  disease  is  very 


OPERATIONS  UPON  INTERNAL  HEMORRHOIDS  145 


extensive,  says : “ I have  never  had  an  unpleasant 
symptom.’  ’ 

Bodenhamer  states  : cc  I have  yet  to  encounter  my 
first  serious  accident.” 

I could  go  on  citing  the  favorable  opinions  of  my 
American  friends  with  regard  to  the  safety  of  liga- 
tion, but  I feel  I need  not  add  anything  to  what  I have 
written  to  prove  the  great  success  in  every  way  of  the 
operation  when  properly  performed,  and  when  the 
patient  is  well  treated  and  placed  in  good  hygienic 
conditions.  It  must  be  clear  that  if  the  death-rate  at 
St  Mark’s  Hospital,  in  so  many  years,  has  been  1 in 
about  670  cases,  equally  good  results  ought  to  be 
obtained  in  private  practice.  If  patients  are  placed  in 
hospital  wards  teeming  with  septic  poisons,  the  deaths 
which  take  place  cannot  be  justly  ascribed  to  the 
operation. 

Mr  Annandale,  of  Edinburgh,  in  the  ‘ Edinburgh 
Monthly  Journal’  for  June,  1877,  publishes  an  article 
“ On  the  Operative  Treatment  of  Internal  Piles,”  and 
comes  to  the  conclusion  that  the  clamp  and  cautery  is 
the  safest  and  best  operation — that  Mr  Annandale 
cannot  base  his  conclusion  on  his  own  experience  is 
quite  evident ; for  he  says  (p.  1080) : “ In  about  two 
hundred  cases  of  this  operation  (the  ligature)  I have 
met  with  at  least  four  instances  of  fatal  pyaemia,” 
a fearful  mortality  in  such  an  operation.  And  he 
goes  on  to  say  that,  “ since  1872  I have  operated 
with  the  clamp  and  cautery  on  twenty-four  patients 
with  one  death  ” — -a  still  higher  rate  of  mortality.  Mr 
Annandale,  however,  still  advocates  the  use  of  the 
clamp  and  cautery,  while  by  his  own  showing  he  has 
had  a greater  fatality  with  these  than  with  the  ligature. 

10 


CHAPTER  X 


COMPLICATIONS  OF  HEMORRHOIDS 

Hemorrhoids  are  not  infrequently  complicated  by 
tbe  co-existence  of  other  affections  of  the  rectum.  I 
have  often  seen  piles,  polypus,  and  fissure  in  tbe  same 
patient. 

I will  mention  tbe  more  frequent  complications,  so 
that  tbe  reader  may  be  warned  against  tbe  error  of 
being  satisfied  with  merely  finding  bis  patient  has 
piles,  without  searching  to  see  if  any  other  malady  be 
present. 

Fissure  or  small  painful  ulcer  is  very  often  associated 
with  haemorrhoids,  and  a careful  examination  is  needed 
to  detect  it,  as  one  of  the  tumours  may  overlap  the 
fissure  so  as  entirely  to  conceal  it.  Always  suspect 
fissure  or  ulceration  when  your  patient  tells  you  he 
suffers  pain  on  defaecation,  or  pain  continuing  long 
after  the  bowel  is  relieved. 

In  operating  on  haemorrhoids,  when  fissure  or  ulcer 
was  found  to  exist,  I always  used  to  divide  the  super- 
ficial fibres  of  the  sphincter  muscles  so  as  to  set  them 
at  rest.  I now  find  this  unnecessary,  as  the  dilatation 
I make  of  those  muscles  allows  the  fissure  or  ulcer  to 
heal.  It  is  well  in  these  cases  not  to  omit  examining 
the  upper  part  of  the  fissure,  to  see  if  any  sinus  runs 
up  from  it ; if  so,  it  must  be  laid  open. 


COMPLICATIONS  OF  HEMORRHOIDS 


147 


Fistula  is  not  so  common  a complication,  but  I have 
often  seen  it.  If  the  fistula  be  weJl  marked  there  is  no 
difficulty  in  the  diagnosis,  but  if  it  be  of  the  blind 
internal  variety,  or  if  the  external  orifice  be  very 
small  and  concealed,  as  it  may  be,  by  an  external  flap 
of  skin,  it  is  quite  possible  to  overlook  it.  I have 
frequently  met  with  examples  of  this.  I will  relate  a 
case  in  point : 

A gentleman  consulted  me  on  the  recommendation  of  Sir  Risdon 
Bennett.  His  statement  was,  that  three  months  ago  he  was  operated 
upon  for  piles,  and  was  pronounced  by  his  surgeon  to  be  cured,  but  he 
still  had  occasional  pain  and  throbbing  in  the  anus ; there  was  also  a 
constantly  recurring  discharge  which  soiled  his  linen  ; it  ceased  for  a 
day  or  two  and  then  returned.  He  had  mentioned  this  to  the  gentleman 
who  operated  upon  him,  and  had  been  told  he  was  only  suffering  from 
a little  weakness  of  the  bowel,  which  would  soon  right  itself;  of  this, 
however,  the  patient  could  not  feel  convinced,  and  he  was  alarmed, 
thinking  that  he  would  have  a return  of  his  haemorrhoids.  The  fre- 
quent discharge  and  staining  of  his  linen  gave  him  great  concern,  and 
worried  him  to  a degree  which  seemed  almost  absurd,  and  quite  dis- 
proportioned  to  the  gravity  of  his  case.  This  I have  often  observed  in 
persons  of  refined  feelings.  In  hospital  practice  patients  do  not  often 
complain  of  a discharge  unless  it  be  very  copious  or  accompanied  by 
pain.  On  a careful  examination  of  this  gentleman  I detected,  just  at 
the  verge  of  the  anus,  and  hidden  by  a small  tab  of  skin,  a minute 
orifice ; a fine  probe  passed  into  this  and  through  a short  sinus,  not 
quite  three  quarters  of  an  inch  in  length,  into  the  bowel.  From  the 
history  of  the  case  (there  having  been  always  the  same  purulent  dis- 
charge) I had  no  doubt  that  this  slight  fistula  had  existed  in  conjunc- 
tion with  the  haemorrhoids,  but  the  major  malady  had  masked  the 
minor  one.  I laid  open  this  sinus,  and  in  a week  the  patient  was  quite 
well  and  relieved  from  his  annoying  discharge. 

When  examining  a case  of  haemorrhoids,  nem*  omit 
to  pass  the  finger  well  into  the  bowel  to  ascertain  that 
no  stricture,  ulceration,  or  malignant  disease  is  pre- 
sent. I have  made  the  same  remark  before,  but  I do 
not  mind  repeating  it,  as  I have  so  often  seen  this 
grave  error  committed.  It  has  many  times  occurred 


148 


COMPLETIONS  OF  HAEMORRHOIDS 


to  me  to  find  that  patients  have  been  operated  upon  in 
metropolitan  hospitals  by  eminent  surgeons,  for  piles, 
when  they  were  suffering  at  the  same  time  from  cancer 
or  ulceration  of  the  bowel.  I need  scarcely  say  that 
an  operation  under  such  conditions  cannot  be  of  any 
benefit  to  the  patient. 

A healthy-looking  young  man,  set.  28,  came  into  my  consulting  room 
quite  recently,  sent  to  me  as  a case  of  piles  for  operation ; a few  ques- 
tions, however,  satisfied  me  that  there  was  something  besides  the  piles. 
An  examination  revealed  carcinoma  high  up  the  rectum,  the  lower 
margin  not  being  nearer  than  three  inches  from  the  anus.  The  termi- 
nation upwards  could  not  be  reached,  but  by  using  my  ball-staff  I found 
indications  of  contraction  and  great  hardness  at  the  upper  part  of  the 
rectum  or  commencement  of  the  sigmoid  flexure. 

Impaction  or  accumulation  of  faeces  in  the  rectum 
or  colon  is  another  complication  worthy  of  mention. 
I have  said  that,  prior  to  operating  upon  piles,  the 
bowels  ought  to  be  thoroughly  cleared  : this  precaution 
is  too  often  neglected.  It  is  remarkable  how  much 
better  patients  do  when  the  portal  system  has  been 
unloaded  by  free  purgation ; and  unless  there  be  some 
care  exercised  in  this  matter  you  may  occasion  your- 
self a good  deal  of  trouble,  to  say  nothing  of  the 
suffering  of  your  patient.  For  my  own  part,  I am 
tolerably  certain  that,  in  the  majority  of  those  cases 
where  the  healing  process  does  not  go  on  kindly,  a 
loaded  colon  and  congested  liver  are  the  chief  cause.  I 
saw  with  a professional  friend  a lady  upon  whom  he  had 
operated  for  slight  internal  haemorrhoids,  and  in  whom 
unhealthy  ulceration  had  followed.  Prior  to  the  opera- 
tion the  patient  was  not  in  bad  health,  and  might 
reasonably  have  been  expected  to  do  well. 

Before  examining  the  rectum  I inquired  as  to  the 
state  of  the  bowels  for  some  time  past,  and  from  the 


COMPLICATIONS  OF  HEMORRHOIDS 


149 


account  given  I was  quite  satisfied  that  there  had 
not  been  a good  clearance  effected.  Moreover, 
although  action  had  taken  place  since  the  operation, 
there  had  been  only  scanty  relief,  and  when  the  patient 
got  out  of  bed  and  stood  up,  she  experienced  inclina- 
tion to  go  to  stool,  and  abortive  straining  on  doing  so. 
On  introducing  my  finger  into  the  bowel  I found  it 
quite  blocked  up  by  hardened  faeces.  This  impaction 
was  got  rid  of  by  manipulation  and  enemata;  then 
aperients  were  given  by  the  mouth,  and  a large  quan- 
tity of  lumpy  fasces  was  evacuated.  When  I saw  this 
patient  again  in  about  ten  days  the  ulceration  was 
nearly  healed. 


I operated  for  haemorrhoids  upon  a young  gentleman  whose  bowels, 
he  said,  generally  acted  fairly,  and  had  done  so  freely  before  the  opera- 
tion ; but  at  the  end  of  a week  he  complained  of  abdominal  pains  and 
desire  to  go  to  stool,  without  having  a satisfactory  evacuation ; this  led 
me  to  examine  his  abdomen,  and  I found  his  colon  quite  dull  on  per- 
cussion, nearly  throughout  its  course.  A brisk  purge  administered 
daily  for  three  days,  and  followed  by  enemata,  produced  most  copious 
action,  and  soon  improved  his  general  condition,  and  hastened  the 
healing  of  the  wounds. 

Another  marked  instance  of  this  complication  occurred  in  a lady 
recommended  to  me  by  my  late  friend  Dr  Daldy.  She  was  a delicate 
person,  who  had  long  suffered  from  the  frequent  combination  of  uterine 
and  rectal  disorder.  She  had  a considerable  and  painful  prolapsus  of 
the  bowel  when  she  came  under  my  care,  her  uterine  malady  having 
been  previously  greatly  ameliorated,  if  not  cured.  The  bowels  acted 
daily  and,  according  to  her  statement,  sufficiently.  She  had  the  usual 
aperient  administered,  and  also  an  enema  prior  to  the  operation,  with 
good  effect ; but  about  the  time  of  the  separation  of  the  ligatures  she 
was  seized  with  severe  abdominal  pains  and  straining,  and  on  examina- 
tion I found  the  rectum  blocked  up  by  hard,  dry,  friable  lumps  of  faeces, 
which  were  with  very  great  difficulty  got  rid  of ; after  this  aloetic 
aperients  procured  the  evacuation  of  a really  enormous  collection  of 
seces ; it  seemed  as  if  the  whole  colon  had  been  fully  charged.  All  this 
delayed  her  recovery,  and  caused  a great  deal  of  pain,  but  eventually 
she  got  well. 


150 


COMPLICATIONS  OF  HAEMORRHOIDS 


Polypus  is  sometimes  found  in  conjunction  with 
hemorrhoids.  I operated  some  time  back  on  the  wife 
of  a well-known  physician,  who,  in  addition  to  hemor- 
rhoids, had  a large  sized,  hard,  pedunculated  polypus. 

My  colleague,  Mr  Groodsall,  assisted  me  once  in 
operating  upon  a lady  who  had  a fissure,  polypus,  and 
hemorrhoids;  her  sufferings  had  been  really  very 
great,  and  she  had  lost  much  blood.  In  these  cases 
a ligature  must  be  placed  upon  the  polypus  as  well  as 
the  piles. 

A gentleman  with  fissure,  haemorrhoids,  and  a very  large  fibrous 
polypus,  with  a hard  peduncle,  was  recently  introduced  to  me  by  my 
friend  Dr  Wm.  Henry  Stone,  of  St  Thomas’s  Hospital.  This  condition, 
by  the  patient’s  history,  had  clearly  existed  for  years,  and  caused  him 
great  pain  when  the  growth  came  outside  the  anus,  as  it  frequently 
did  at  stool.  This  gentleman  had  been  operated  on  twelve  years 
before  my  seeing  him,  a small  polypus  being  then  removed. 


CHAPTER  XI 

hemorrhage  after  operations  upon  piles 

This  will  occasionally  take  place,  and  it  may  be  either 
accidental,  recurrent,  or  secondary. 

Just  as  in  midwifery  you  may  go  on  for  years  with- 
out the  occurrence  of  an  untoward  event,  and  then  get 
a batch  of  troublesome  cases,  so  it  is  in  this  operation 
— you  may  perform  it  a large  number  of  times  without 
the  slightest  unpleasant  symptom  resulting,  and  then 
have  a run  of  cases  which  cause  you  more  or  less 
anxiety. 

If  the  operation  be  carefully  done,  primary  haemor- 
rhage is  very  rare ; occasionally,  when  large  and  very 
vascular  hemorrhoids  are  ligatured,  and  there  is  also 
much  superabundant  skin  cut  away,  a small  vessel 
will  bleed  when  the  patient  recovers  from  the  shock  : 
this  is  a trivial  matter,  and  a ligature  is  easily  applied. 
I think  it  will  scarcely  ever  occur  if  the  precaution  of 
putting  on  a good  pad  of  wool  and  a T-bandage  is 
adopted.  JSTow  and  then,  particularly  if  the  patient 
has  been  unruly  under  the  operation,  the  ligature  may 
not  have  been  placed  quite  at  the  bottom  of  the  incision, 
and  some  bleeding  may  then  result.  The  ready  way  to 
arrest  this  is  to  draw  down  the  bowel  by  the  ligatures, 
the  patient  assisting  you  by  straining ; you  will  then, 
in  all  probability,  be  able  to  see  the  bleeding  vessel 


152  HiEMOERHAGE  AFTEE  OPERATIONS  UPON  PILES 

and  tie  it.  If  you  do  not  see  it,  or  if  a general  oozing 
is  apparent,  pass  all  the  ligatures  through  a hole  made 
in  the  middle  of  a small  round  sponge,  then  tie  them 
across  a piece  of  stick,  and  twist  this  round.  In  this 
way  you  construct  a sort  of  tourniquet,  and  can  make 
firm  and  strong  pressure  with  the  sponge,  so  that  no 
bleeding  can  take  place.  In  a few  hours  after  it  is  all 
arrested  the  stick  may  be  removed. 

In  the  old  plan  of  operating  with  a double  ligature 
and  transfixion  of  the  base  of  the  haemorrhoid,  bleeding 
used  from  time  to  time  to  occur  from  perforation  of  a 
vessel — usually  a vein — by  the  needle.  When  this 
takes  place,  on  the  ligatures  being  tied,  the  vessel 
would  be  more  or  less  torn  open,  and  bleeding  would 
ensue  at  the  time,  or  shortly  afterwards. 

I have  more  than  once  been  called  to  see  a patient 
to  whom  this  accident  had  occurred.  It  is  easily  reme- 
died by  drawing  down  the  piles  by  the  ligatures,  and 
placing  one  ligature  above  the  spot  where  the  bleeding 
haemorrhoid  was  transfixed. 

In  cases  of  sloughing  haemorrhoids  the  parts  are 
sometimes  so  much  disintegrated  that  very  free 
haemorrhage  takes  place ; at  the  same  time  a ligature 
is  not  easily  applied,  in  consequence  of  the  tissues 
readily  breaking  down. 

I once  Lad  a rather  startling  accident  occur  after  operating.  A 
gentleman  came  up  from  the  country,  and  was  operated  upon  by  me 
for  piles ; it  was  a bad  case,  and  five  ligatures  were  applied.  The  night 
following  the  operation  he  was  attacked  quite  suddenly  with  delirium 
tremens,  and  in  a paroxysm  of  mania  tore  off  three  of  the  ligatures. 
The  loss  of  blood  was  very  considerable.  When  I arrived  at  the  house 
I found  the  patient,  the  bed,  and  the  floor  of  the  room  covered  with 
blood.  I had  much  difficulty  in  placing  ligatures  on  the  bleeding 
vessels,  as  the  patient,  although  very  collapsed,  was  capable  of  offering 
resistance.  Curiously  enough,  he  did  exceedingly  well  afterwards ; I 


HEMORRHAGE  AFTER  OPERATIONS  UPON  PILES  153 


do  not  think  that  the  accident  delayed  his  recovery  a single  day.  He 
had  not  been  an  habitual  drunkard,  but  the  fear  of  the  operation  in- 
duced him,  for  about  a week  before  he  came  up  to  undergo  it,  to  drink 
quantities  of  champagne  and  brandy ; this,  with  the  chloroform  and 
the  shock  of  the  operation,  brought  on  acute  delirium. 

Another  case  of  accidental  haemorrhage  occurred  to  a patient  of  my 
friend  Mr  Blackman,  of  Highbury.  I operated  for  him  upon  an  elderly 
gentleman  who  had  a very  large  haemorrhoid,  which  had  undergone 
fibroid  degeneration ; it  was  situated  dorsally,  was  as  large  as  a hen’s 
egg,  and  always  came  down  at  stool,  giving  a great  deal  of  trouble. 
Ulceration  had  taken  place  at  the  upper  part  of  the  pile.  I placed  a 
ligature  upon  it,  and  then  cut  the  tumour  off.  At  the  time  of  tighten- 
ing the  ligature  I felt  that  the  tissues  were  very  friable,  and  I examined 
the  site  of  the  ligature  to  see  if  it  had  cut  through  much,  but  could 
not  discover  that  it  had  done  so,  and  there  was  no  bleeding.  When  I 
saw  the  patient  in  the  morning  with  Mr  Blackman,  we  found  that  con- 
siderable haemorrhage  had  taken  place  since  4 a.m.,  the  cause  being 
probably  as  follows  : — He  had  not  passed  any  water,  and  feeling  a very 
urgent  desire,  he  jumped  quickly  out  of  bed,  and  strained  violently  to 
empty  his  bladder ; at  the  time  he  was  doing  this  he  felt  something 
give  way  in  the  rectum,  and  on  getting  back  into  bed  his  wife  observed 
that  he  was  bleeding.  I forcibly  dilated  his  sphincter,  and  then  with  a 
vulsellum  drew  down  the  bowel,  and  placed  another  ligature  above  the 
first  one.  This  at  once  arrested  the  bleeding,  but  the  next  day  but  one 
it  recurred  to  an  alarming  extent,  and  I found  the  parts  so  soft  and 
sloughy  that  no  ligature  would  hold ; under  these  circumstances  I 
plugged  the  rectum  (in  the  manner  I will  presently  describe).  This 
plug  was  retained  for  about  ten  days,  and  he  had  no  more  haemorrhage, 
and  eventually  did  well,  although  for  some  time  he  gave  Mr  Blackman 
and  myself  no  little  anxiety. 

I will  relate  one  more  case.  In  the  year  1866  I operated  at  St  Mark’s 
with  the  clamp  and  cautery  upon  a really  severe  case  of  internal  haemor- 
rhoids. The  parts  were  very  vascular,  and  I had  considerable  difficulty 
in  controlling  the  haemorrhage,  having  to  apply  the  cautery  a good 
many  times.  When  the  patient  left  the  operating  table  there  was  no 
bleeding  at  all ; but  in  the  evening  I was  sent  for  by  the  house-surgeon, 
as  very  free  arterial  haemorrhage  had  come  on.  The  patient  was  very 
timid  and  the  parts  very  tender,  so  that  I had  much  trouble  to  intro- 
duce a speculum ; and  when  I did  I could  not  find  the  spot  whence  the 
blood  came.  I ordered  the  injection  of  ice-water  and  perchloride  of 
iron ; this  had  the  effect  of  arresting  the  flow,  but  only  temporarily. 

When  I saw  the  patient  early  in  the  morning  I was  told  that  he  had 
lost  a good  deal  of  blood  during  the  night,  and  the  flux  was  still  going 


154  HEMORRHAGE  AFTER  OPERATIONS  UPON  PILES 


on,  so  I determined  to  find  the  vessel  if  it  were  possible.  Accordingly 
I passed  my  finger  into  the  bowel,  and  on  that  I guided  a vulsellum, 
and,  catching  a good  hold  of  the  rectum,  I pulled  that  part  down; 
while  that  was  held  I used  another  vulsellum  on  the  other  side  of  the 
bowel,  and  thus  succeeded  in  bringing  the  inside  of  the  rectum  well  into 
view.  This  done,  I found  two  points  from  which  the  blood  escaped  in 
jets,  so  I placed  ligatures  upon  these  vessels,  and  the  haemorrhage  was 
arrested. 

I leave  tlie  reader  to  imagine  how  much  pain  the 
patient  must  have  suffered  from  this  proceeding.  He 
had  such  a tendency  to  faint  that  I was  afraid  to  give 
him  chloroform.  Ether  was  not  then  in  vogue. 

These  cases  may,  I think,  be  correctly  styled  acci- 
dental or  recurrent  hemorrhage.  Of  late  years  I have 
had  this  form  of  haemorrhage  occur  much  less  fre- 
quently. As  a rule,  I should  say  what  we  have  most 
to  fear  is  secondary  haemorrhage,  which  usually  comes 
on  at  or  about  the  time  of  the  separation  of  the  liga- 
tures. This  form  of  bleeding  occurs  generally  in 
elderly  people  of  broken-down  constitutions,  or  in  those 
who  have  been  very  free  livers.  I may  say,  as  far  as 
my  experience  goes,  that  this  haemorrhage  is  usually 
more  venous  than  arterial.  Of  course  there  are  ex- 
ceptions to  the  rule  of  its  occurrence  in  elderly  people. 
Here  is  one : 

A gentleman,  set.  23,  bad  all  bis  life  suffered  from  rectal  disease : 
when  a child  from  procidentia,  and  by  tbe  time  be  was  eighteen  from 
bleeding  haemorrhoids.  When  I saw  him  he  had  a prolapse  of  the 
lower  part  of  one  side  of  the  rectum,  which  came  down  on  very  slight 
exertion ; he  was  very  thin  and  weak,  and  subject  to  fainting.  I put 
two  ligatures  upon  his  prolapsus,  assisted  by  my  colleague  Mr  Goodsall. 
Mr  Buxton  Shillitoe  administered  the  chloroform  with  his  usual  care 
and  discrimination,  and  although  very  little  was  given,  and  the  opera- 
tion did  not  take  one  minute  to  perform,  the  patient  fainted,  and  we 
had  considerable  trouble  in  recovering  him.  I was  quite  convinced 
that  had  the  chloroform  been  given  recklessly  or  unskilfully  death 
would  have  ensued. 


HAEMORRHAGE  AFTER  OPERATIONS  UPON  PILES  155 


This  gentleman  went  on  very  well  indeed  until  the  sixth  day,  when 
the  ligatures  came  away  on  the  bowels  acting,  Soon  after  this — he  had 
returned  to  his  bed — he  said  he  felt  faint,  then  that  he  wanted  to  go  to 
stool ; and  on  being  assisted  up  to  do  so  he  nearly  filled  the  pan  with 
dark  blood  and  fainted  away.  I was  sent  for  in  great  haste,  and 
directly  saw  that  he  had  lost  and  was  still  losing  a large  quantity  of 
blood.  This  was  not  a case  in  which  one  could  afford  to  temporize,  so 
I at  once  plugged  his  bowel  with  cotton  wool  and  subsulphate  of  iron, 
which  I had  with  me.  I was  quite  sure  that  it  was  no  use  to  search  for 
the  bleeding  vessel  or  vessels.  The  plugging  immediately  arrested  the 
hemorrhage,  and  I kept  the  wool  in  for  ten  days ; I then  carefully 
removed  it,  and  no  further  bleeding  took  place.  The  patient  soon  got 
quite  well.  This  is  the  only  case  of  severe  secondary  hemorrhage  I 
ever  had  in  a young  person. 

An  elderly  gentleman  came  from  the  country  to  be  under  my  care. 
He  had  been  much  in  hot  climates,  had  led  rather  a dissipated  life,  and 
worked  very  hard.  He  was  only  fifty-four,  but  he  looked  sixty-five  at 
least.  He  suffered  from  a constantly  prolapsed  haemorrhoid.  I saw  no 
reason  why  it  should  not  be  removed ; accordingly  I applied  a ligature 
in  my  usual  way.  The  patient  did  capitally  until  the  fifth  day,  when 
the  ligature  came  away  on  his  going  to  stool.  I saw  him  in  the  after- 
noon and  he  was  very  comfortable,  and  said  he  should  get  up  and  lie  on 
the  sofa.  I made  no  objection,  and  he  did  so. 

At  night  I was  summoned  hastily,  as  he  was  bleeding ; when  I arrived 
I found  him  quite  collapsed,  and  the  blood  was  literally  pouring  out 
from  his  rectum.  The  haemorrhage  had  come  on  suddenly  when  he 
was  moving  from  his  sofa  in  the  sitting-room  to  the  bedroom  on  the 
same  floor.  I plugged  instantly  and  arrested  the  bleeding;  he  suffered 
a good  deal  of  distress  from  flatulence,  and  I was  compelled  to  remove 
the  wool  and  sponge  on  the  sixth  day.  To  my  intense  annoyance, 
after  twenty-four  hours  the  haemorrhage  recurred  quite  as  badly  as  at 
first.  I was  thus  obliged  to  replug  the  rectum,  but  this  time,  not 
wishing  to  remove  the  plug  early,  I adopted  the  precaution  of  intro- 
ducing a full-sized  elastic  catheter  at  the  side  of  the  wool,  so  that  he 
was  able  to  get  rid  of  flatus  through  it.  This  was  all  retained  for 
nineteen  days,  when  I gradually  and  carefully  drew  the  plugging  out : 
there  was  no  further  bleeding.  I am  free  to  confess  that  this  was  a 
very  anxious  case. 

A man,  set.  62,  was  operated  upon  by  me  at  St  Mark’s  Hospital,  in 
July,  1868.  He  was  a feeble  man  and  had  no  power  in  his  sphincter 
muscles.  He  suffered  from  prolapsed  haemorrhoids,  which  were  always 
down.  I used  the  clamp  and  cautery. 


156  HEMORRHAGE  AFTER  OPERATIONS  UPON  PILES 


On  the  fourth  day  haemorrhage  commenced  after  action  of  the 
bowels ; at  first  the  blood  was  small  in  quantity,  and  passed  only  when 
moved  or  coughed ; it  came  away  fluid,  and  also  in  small  clots  ; it  was 
venous  in  character.  Ice  water  with  perchloride  of  iron  was  injected, 
but  failed  to  arrest  it.  When  I saw  him  he  was  very  pale  and  faint, 
and  the  haemorrhage  was  nearly  constant,  the  blood  slowly  trickling 
out  of  the  anus.  On  examination  I found  the  bowel  full  of  blood.  I 
plugged  the  rectum  fully  with  cotton  wool,  into  which  was  dusted  the 
subsulphate  of  iron  ; this  at  once  stopped  the  bleeding.  The  plug  was 
retained  for  six  days,  and  when  it  was  removed  there  was  no  return  of 
haemorrhage.  This  patient  was  very  weak  and  ill  for  some  time,  and 
he  suffered  from  an  attack  of  purpura.  He  rallied,  however,  under 
good  diet  and  stimulants,  and  left  the  hospital  quite  recovered. 


When  bleeding  is  taking  place  internally  and  in 
consequence  of  the  tightness  of  the  sphincter  the  blood 
does  not  escape,  the  patient  will  always  tell  yon  “ that 
he  feels  something  running  inside  the  bowel,”  and  this 
may  continue  until  the  rectum  (and  even  the  sigmoid 
flexure)  is  full  of  clots  and  fluid  blood.  If  you  suspect 
this  and  pass  your  finger  into  the  anus,  you  will  excite 
contraction  of  the  gut,  and  the  contents  will  then  be 
expelled  with  more  or  less  force.  The  trickling  sen- 
sation I always  take  as  a pretty  certain  indication  of 
internal  bleeding,  and  I act  accordingly.  If  you  dilate 
the  sphincters  prior  to  operating,  this  retention  of  blood 
in  the  bowel  is  not  likely  to  take  place,  as  there  can  be 
no  contraction  of  the  orifice  of  the  anus.  This  is 
another  advantage  resulting  from  dilatation.  These 
cases  do  very  well  if  prompt  and  judicious  treatment  be 
adopted.  I have  never  lost  a patient,  although  I have 
seen  persons  in  considerable  danger.  If  the  bleeding 
were  allowed  to  continue  long,  I have  not  the  slightest 
doubt  that  a fatal  issue  would  be  the  result ; so  I will 
in  some  detail  describe  the  method  of  treatment  I 
consider  most  advisable. 


HAEMORRHAGE  AFTER  OPERATIONS  UPON  PILES  157 

I have  found  it  utterly  futile  in  cases  of  secondary 
hgemorrhage  to  try  and  place  a ligature  round  the. 
vessels  ; it  is  usually  the  large  veins  or  venous  sinuses 
which  are  opened  by  sloughing  or  ulceration,  and  when 
you  introduce  a speculum  and  try  to  find  the  source 
of  bleeding,  you  can  only  see  that  the  whole  rectum  is 
filled  with  blood,  and  on  passing  your  finger  you  will 
feel  a quantity  of  clots. 

When  called  to  cases  of  severe  haemorrhage,  always 
arm  yourself  with  a full-sized,  bell-shaped  sponge  and 
plenty  of  cotton  wadding ; take  also  some  subsulphate 
of  iron,  or  if  you  have  not  that,  powdered  alum  or 
tannin.  Pass  a strong  silk  ligature  through,  near  the 
apex  of  your  cone-shaped  sponge,  and  bring  it  back 
again,  so  that  the  apex  of  the  sponge  is  held  in  a loop 
of  the  thread.  Then  wet  the  sponge,  squeeze  it  dry, 
and  powder  it  well,  filling  up  the  lacunse  with  the  iron 
or  other  astringent.  Pass  the  forefinger  of  your  left 
hand  into  the  bowel,  and  upon  that  as  a guide  push  up 
the  sponge — apex  first — by  means  of  a metal  rod,  bougie, 
pen-holder,  or  a rounded  piece  of  wood,  if  you  can  get 
nothing  better.  Now,  this  sponge  should  be  carried 
up  the  bowel  at  least  five  inches,  the  double  thread 
hanging  outside  the  anus.  When  this  is  so  placed  fill 
up  the  whole  of  the  rectum  below  the  sponge  thoroughly 
and  carefully  with  cotton  wool  well  powdered  with  the 
alum  or  iron.  When  you  have  completely  stuffed  the 
bowel,  take  hold  of  the  silk  ligature  attached  to  the 
sponge,  and  while  with  one  hand  you  pull  down  the 
sponge,  with  the  other  hand  push  ujp  the  wool.  This 
joint  action  will  spread  out  the  bell-shaped  sponge, 
like  opening  an  umbrella,  and  bring  the  wool  com- 
pactly together ; if  this  is  carefully  done  no  bleeding 


158  HAEMORRHAGE  AFTER  OPERATIONS  UPON  PILES 

can  possibly  take  place  either  internally  or  externally. 
Half  measures  in  these  cases  are  worse  than  useless,  as 
valuable  time  is  thereby  lost.  This  plug  should  remain 
in  at  least  a week,  and  it  may  be  retained  a fortnight 
or  more.  It  may  be  thought  that  much  straining  and 
pain  would  be  caused  by  it.  I assure  you  this  is  not 
the  case ; if  you  keep  your  patients  fairly  under  the 
influence  of  opium  they  very  rarely  complain.  The 
only  trouble  may  be  wind,  and  this  often  will  find  its 
own  way  out.  If  you  fear  this,  and  have  a male 
catheter  or  flexible  tube  handy,  you  may  introduce  it 
through  the  centre  or  by  the  side  of  the  sponge,  packing 
the  wool  around  it.  I have  done  this  several  times, 
and  found  the  patients  passed  not  only  wind  through 
it,  but  also  broken-down  blood  and  liquid  faeces.  I am 
sure  you  need  never  fear  a case  of  haemorrhage  if  you 
only  plug  methodically  and  thoroughly.  I think  very 
highly  of  the  subsulphate  of  iron ; no  styptic  in  my 
opinion  answers  as  well.  It  is  far  superior  to  the 
per  chloride,  as  it  does  not  cause  burning  or  pain.  In 
slight  cases  of  bleeding  the  injection  of  a strong  solu- 
tion of  tannin  or  even  ice  water,  keeping  a lump  of 
ice  on  the  sacrum,  and  the  patient  cool  and  quiet, 
may  be  sufficient,  but  I say  never  leave  a patient  who 
has  at  all  continuous  or  free  haemorrhage  without  the 
plug. 

Practitioners  who  are  not  frequently  operating  on 
haemorrhoids  cannot  be  expected  to  possess  all  the 
most  modern  appliances,  but  I can  recommend  my 
friend  Mr  Gowlland’s  tubes,  which  are  made  of  vul- 
canite, shaped  like  a bougie,  seven  inches  in  length  and 
about  one  inch  in  diameter ; the  base  terminates  in  a 
rim,  which  is  perforated,  so  that  it  can  be  sewn  to  a 


HEMORRHAGE  AFTER  OPERATIONS  UPON  PILES  159 

bandage.  I have  had  tubes  made  with  holes  two  inches 
from  the  apex,  so  that  sponge  can  be  sewn  on  around 
them.  When  this  is  passed  up  the  rectum  you  pack 
wool  all  around  it.  The  advantages  are  obvious ; flatus, 
liquid  fseces,  and  broken-down  blood  can  pass ; you  can 
also  inject  frequently  a weak  solution  of  Condy’s  fluid, 
which  will  keep  the  part  clean  and  sweet ; do  not  use 
carbolic  acid,  as  it  frequently  gives  rise  to  much 
irritation. 

The  after-treatment  of  these  cases  requires  con- 
siderable care  and  attention  to  details ; generally  the 
patient  is  very  greatly  alarmed  at  the  bleeding,  but  his 
fears  will  be  soon  allayed  if  he  finds  you  are  prompt 
and  confident  of  your  own  powers  to  succour  him. 
After  the  haemorrhage  is  arrested  by  the  plugging,  the 
recumbent  position  must  be  maintained,  and  on  no 
account  whatever  should  an  upright  posture  be  assumed. 
If  the  packing  be  tight,  frequently  retention  of  urine 
will  occur,  and  you  must  pass  a catheter;  but  you 
should,  if  possible,  at  once  teach  the  patient  to  intro- 
duce the  instrument  for  himself.  A Mercier’s  flexible 
coudee  catheter  goes  so  readily  into  the  bladder  that 
any  but  the  most  timid  person  may  in  one  lesson 
acquire  the  art.  The  buttocks  and  lower  part  of 
the  back  should  be  kept  cool.  I employ  dry  cold, 
by  means  of  ice  in  an  india-rubber  bag,  applied  to  the 
sacrum.  If  the  patient  is  exceedingly  collapsed  do  not 
apply  cold.  I have  found  hot  sponges  to  the  sacrum 
advantageous.  Stimulants  may  be  given,  but  it  is 
better,  if  possible,  to  wait  for  some  hours  and  observe 
what  amount  of  reaction  takes  place  ; this  is  sometimes 
considerable,  and  will  make  you  wish  that  you  had 
withheld  alcohol  or  used  it  very  sparingly.  As  soon 


160  HAEMORRHAGE  AFTER  OPERATIONS  UPON  PILES 

as  it  can  be  taken,  nourishment  is  to  be  given,  and 
Liebig’s  cold  soup,  which  can  be  quickly  prepared,  I 
have  found  a wonderful  restorative.*  Hot  liquids,  I 
need  scarcely  say,  are  to  be  avoided.  I do  not  think 
it  necessary  to  keep  these  patients  entirely  on  fluid 
diet ; directly  they  can  take  solid  food  let  them  have  it, 
but  it  should  be  nourishing  and  easy  of  digestion. 
As  secondary  haemorrhage  generally  occurs  in  persons 
whose  blood  and  tissues  are  deficient  in  plastic  mate- 
rial, the  aim  of  treatment  must  be  to  remedy  that 
defect,  and  thoroughly  nutritious  food  judiciously  ad- 
ministered is,  I imagine,  the  most  valuable  means  to 
that  end. 

I do  not  place  much  trust  in  the  internal  use  of 
astringent  remedies.  The  hypodermic  injection  of 
ergotine  I shall  use  when  I have  a case  that  I con- 
sider not  very  urgent,  but  I always  prescribe  iron,  not 
only  as  a haemostatic,  but  also  for  its  blood-repairing 
property.  I prefer  either  the  Tinct.  Ferri  Per- 
chloridi,  or  the  Liq.  Ferri  Peracetatis.  If  the  stomach 
bears  this  well,  full  doses  may  be  given  twice  or  thrice 
in  the  day ; in  addition,  a pill  containing  one  grain  of 
solid  opium  night  and  morning,  or  at  night  only,  if  the 
bowels  do  not  exhibit  any  tendency  to  act  and  there  is 
no  straining,  will  generally  meet  the  requirements  of 
the  case. 

* Liebig’s  cold  soup  is  prepared  tbus  : — Take  8 oz.  of  raw  lean  beef, 
finely  minced,  put  it  into  20  oz.  of  cold  water,  add  10  drops  of  strong 
hydrochloric  acid  and  a little  salt ; let  it  stand  half  an  hour  and  then 
strain.  One  or  two  ounces  may  be  given  every  half  hour. 


CHAPTER  XII 

PROCIDENTIA  RECTI 

There  is  sometimes  a confusion  of  ideas  occasioned 
by  the  use  of  the  words  procidentia  and  prolapsus. 

Internal  hemorrhoids,  when  they  have  come  down 
outside  the  anus,  are  said  to  be  prolapsed,  and  the  case 
is  frequently  called  prolapsus  ani ; but  there  is  a very 
marked  pathological  distinction  to  be  observed  between 
prolapsed  internal  haemorrhoids  and  prolapsus  of  the 
rectum. 

Prolapsus  is  a descent  of  the  lowest  part  of  the 
rectum,  the  mucous  membrane  and  submucous  tissue, 
both  occasionally  thickened,  being  turned  out  of  the 
anus.  Now,  this  condition  differs  from  prolapsed 
hsemorrhoids  thus  : — The  haemorrhoids  exist  as  sepa- 
rate and  distinct  rounded  tumours,  while  the  pro- 
lapsus may  be  seen  to  surround  the  anus  without  any 
division  into  definite  tumours,  only  the  natural  folds 
of  the  bowel  being  observed ; generally  there  is  one 
distinct  fold  towards  the  perineum,  and  the  remainder 
forms  a horseshoe-shaped  projection  around  the  sides 
and  back  part  of  the  anus.  The  appearance  and 
touch  also  of  prolapsus  differ  from  piles  in  its  not 
being  smooth,  hard,  and  shiny,  but  soft  and  velvety. 

If  you  thought  fit,  you  would  operate  upon  such  a 

11 


162 


PROCIDENTIA  RECTI 


case  in  the  same  manner  as  you  would  upon  internal 
hsemorrhoids,  with  this  exception,  that  the  larger  seg- 
ment of  the  rectum  will  require  to  be  divided  vertically 
into  two  or  three  portions,  in  order  that  several  liga- 
tures may  be  applied  to  ensure  a complete  strangu- 
lation of  the  part. 

True  procidentia  is  the  descent  of  the  upper  part  of 
the  rectum,  in  its  whole  thickness,  or  all  its  coats, 
through  the  anus. 

There  is  a variety  of  procidentia  which  one  may  call 
intussusception,  the  upper  part  of  the  rectum  descend- 
ing through  the  lower  part ; this  is  diagnosed  from 
ordinary  procidentia  by  there  being  a more  or  less  deep 
sulcus  around  the  inner  column  of  the  intestine,  so  that 
there  are,  as  it  were,  two  cylinders  of  rectum,  one 
inside  the  other.  This  condition  is  often  associated 
with,  and  caused  by,  the  growth  of  a polypus ; it  gives 
rise  to  a train  of  very  distressing  symptoms,  which  may 
continue  long  after  the  removal  of  the  growth  which 
has  been  the  starting-point  of  the  malady.  I had  a 
lady  under  my  care,  sent  to  me  by  Dr  Gervis,  who 
some  time  before  had  a rectal  polypus  removed,  but  she 
still  had  great  suffering ; a sensation  of  burning  and  ful- 
ness in  the  bowel  attended  with  tenesmus  and  difficulty 
in  defsecation.  She  has  an  intussusception  of  the  upper 
part  of  the  rectum  into  the  middle  and  lower  part; 
the  bowel  does  not  generally  come  outside  the  anus, 
but  approaches,  when  she  strains,  near  to  it.  I have 
seen  many  cases  of  this  kind.  One  very  troublesome 
case,  a middle-aged  single  lady,  sent  me  by  Dr  J. 
Grey  Glover,  had  an  intussusception  and  constipa- 
tion, with  constant  straining;  she  suffered  greatly, 
and  took  all  kinds  of  aperients  and  other  medicines. 


PROCIDENTIA  RECTI 


163 


At  last  she  regained  much  comfort  by  following  out 
my  suggestion — of  always  having  action  of  the  bowels 
lying  down,  and  keeping  recumbent  for  an  hour  or  so 
afterwards.  The  worst  thing  that  can  be  done  for 
these  patients  is  to  give  way  to  their  craving  for 
purgatives. 

Sometimes  a procidentia  occurs  conjointly  with  in- 
ternal hsemorrhoids  ; in  this  case,  when  the  procidented 
gut  is  gently  returned,  there  still  remains  outside  the 
anus  a ring  of  hsemorrhoids,  or  loose  and  thickened 
mucous  membrane ; and  I may  mention  that  these 
cases  are  the  most  satisfactory  to  treat,  as  ligature  of 
the  haemorrhoids  will  almost  certainly  cure  the  proci- 
dentia. This  was  clearly  shown  by  the  late  Mr  Hey, 
of  Leeds. 

Procidentia  of  the  rectum  is  more  often  seen  in 
children  than  adults,  although  it  is  by  no  means  a rare 
affection  in  women — particularly  those  who  have  borne 
many  children — and  in  men  in  advanced  years.  Pro- 
cidentia in  children  is  much  favoured  by  the  formation 
of  the  pelvis,  the  sacrum  being  nearly  straight.  More- 
over, all  infants  strain  violently  when  their  bowels  act, 
even  when  their  motions  are  quite  soft.  There  appears 
to  be  some  physiological  necessity  for  this,  which  I do 
not  pretend  to  explain  or  understand ; but  these  facts 
are  not  quite  sufficient  to  account  for  the  proneness  of 
children  to  this  malady;  there  is  always,  in  addition, 
some  inherent  weakness  or  extraneous  source  of  irri- 
tation present  by  which  excessive  straining  is  caused. 
We  may  mention  diarrhoea — often  the  result  of  strumous 
inflammation  of  the  intestines,  worms,  stone  in  the 
bladder,  phimosis,  polypus  recti,  &c.  There  are  many 
cases,  however,  in  which  we  can  assign  no  special  cause, 


164 


PROCIDENTIA  RECTI 


where  the  child  is  not  manifestly  unhealthy,  and  no 
source  of  irritation  can  be  detected. 

I am  sure  that  the  very  bad  custom  of  placing  a child 
upon  the  chamber  utensil,  and  leaving  it  there  for  an 
indefinite  period,  as  practised  by  many  mothers  and 
nurses,  is  a fertile  cause  of  procidentia. 

In  children  the  treatment  is  generally  successful ; it 
should  first  be  addressed  to  the  removal  of  any  source 
of  irritation ; this  accomplished,  a cure  is  speedily 
effected.  When  no  source  of  irritation  can  be  dis- 
covered, the  general  health  must  be  attended  to.  The 
child  should  never  be  allowed  to  sit  and  strain  at  stool ; 
the  motions  should  be  passed  lying  upon  the  side  at  the 
edge  of  the  bed,  or  in  a standing  position,  and  one 
buttock  should  be  drawn  to  one  side,  so  as  to  tighten 
the  anal  orifice  while  the  faeces  are  passing ; this  device 
I have  found  to  be  very  useful ; it  is  recommended  in 
c Druitt’s  Surgery,’  but  upon  whose  authority  I do  not 
know. 

When  the  bowels  have  acted,  the  protruded  part 
ought  to  be  well  sluiced  with  cold  water,  and  afterwards 
a solution  of  alum  and  oak  bark,  infusion  of  matico, 
krameria,  or  weak  carbolic  acid,  should  be  thoroughly 
applied  with  a sponge ; the  bowel  must  then  be  returned 
by  gentle  pressure,  and  the  child  should  remain  recum- 
bent for  some  little  while,  lying  upon  its  face  on  a couch, 
before  running  about.  If  there  be  any  intestinal  irri- 
tation, I generally  order  small  doses  of  Hydrarg.  cum 
Creta,  with  rhubarb,  at  bedtime,  and  steel  wine  two  or 
three  times  in  the  day.  When  the  child  is  very  ill- 
nourished,  cod-liver  oil  does  much  good  ; the  diet  should 
be  nourishing  and  digestible. 

If  these  mild  measures  do  not  succeed,  I find  the 


PROCIDENTIA  RECTI 


165 


application  of  strong  nitric  acid  the  best  remedy. 
Chloroform  should  be  given,  and  the  protruded  gut 
well  dried.  The  acid  must  be  applied  all  over  it,  care 
being  taken  not  to  touch  the  verge  of  the  anus  or  the 
skin.  The  part  is  then  to  be  oiled  and  returned,  and 
the  rectum  stuffed  thoroughly  with  wool ; a pad  must 
after  this  be  applied  outside  the  anus,  and  kept  firmly 
in  position  by  strapping  plaster,  the  buttocks  being  by 
the  same  means  brought  closely  together ; if  this  pre- 
caution be  not  adopted,  when  the  child  recovers  from 
the  chloroform,  the  straining  being  urgent,  the  whole 
plug  will  be  forced  out,  and  the  bowel  will  again  pro- 
trude. When  the  pad  is  properly  applied,  the  strain- 
ing soon  ceases,  and  the  child  suffers  little  or  no  pain. 
I always  order  a mixture  of  aromatic  confection,  with 
a drop  or  two  of  tincture  of  opium,  so  as  to  confine  the 
bowels  for  four  days.  I then  remove  the  strapping, 
and  give  a teaspoonful  of  castor  oil.  When  the  bowels 
act  the  plug  comes  away,  and  there  is  no  descent  of 
the  rectum. 

I have  had  experience  of  this  treatment  in  a great 
many  cases ; I never  knew  it  to  fail  if  properly  carried 
out,  and  only  on  two  occasions  have  I had  to  apply  the 
acid  more  than  once.  The  result,  also,  is  not  a tem- 
porary but  a permanent  benefit. 

Procidentia  in  the  adult  is  a very  much  more  un- 
manageable affection,  and  is  supposed  in  many  instances 
to  be  quite  incurable. 

Numerous  operative  procedures  haye  been  recom- 
mended for  the  cure  of  this  malady  in  its  advanced 
stages,  but  I cannot  say  that  I am  satisfied  with  any 
of  them,  save  one  to  be  presently  described ; all  the 
others  I have  seen  fail.  The  application  of  fuming 


166 


PROCIDENTIA  RECTI 


nitric  acid,  or,  what  I think  preferable,  the  acid  nitrate 
of  mercury,  often  does  much  good,  although,  unfor- 
tunately, the  relief  is  usually  only  temporary ; I have 
had  patients  to  whom  the  acid  has  been  frequently, 
and  very  thoroughly  applied,  but  without  effecting  a 
cure.  The  use  of  the  acid  in  such  cases  is  not  at  all 
painful  if  the  skin  be  not  touched ; it  causes  only  a 
burning  sensation,  which  soon  passes  off.  As  in  chil- 
dren, the  gut  should  be  oiled  before  returning  it,  and 
the  bowels  should  be  confined  for  a few  days. 

In  old  persons,  or  in  those  with  a broken-down  con- 
stitution, a very  free  application  of  the  acid  is  to  be 
deprecated,  as  a deep  slough  may  form,  some  vessel 
be  opened  on  its  separation,  and  severe  haemorrhage 
take  place ; this  complication  occurred  to  me  at  St 
Mark’s  in  the  person  of  an  elderly  woman  of  feeble 
powers ; she  lost  very  much  blood,  and  the  flux  was 
arrested  only  by  plugging  the  rectum.  The  same 
observation  applies  to  the  use  of  acid  to  venous 
haemorrhoids  in  old  people.  I saw  a very  profuse 
haemorrhage  take  place  in  an  old  man  who  had  been  a 
free  drinker,  and  had  great  dilatation  of  the  veins  at 
the  lower  part  of  the  rectum,  probably  depending  upon 
a diseased  condition  of  liver.  It  was  not  thought 
desirable  to  use  the  ligature,  and  nitric  acid  was 
applied  ; it  caused  a considerable  slough,  and  bleeding 
commenced  in  four  days ; before,  in  fact,  the  slough 
had  separated.  This  patient  nearly  lost  his  life. 

A stricture  of  the  rectum  may  result  from  the  use 
of  the  fuming  nitric  acid ; I have  seen  this  occur  on 
several  occasions,  and  very  notably  in  a girl  at  St 
Mark’s  Hospital,  to  whom  acid  had  to  be  applied  three 
times,  and  in  whom  a stricture  formed  about  three 


PROCIDENTIA  RECTI 


167 


and  a half  inches  from  the  anus ; this  gave  us  much 
trouble,  as,  although  the  bowel  did  not  come  down, 
the  symptoms  were  quite  as  distressing  as  those  of 
that  affection. 

I have  used  strong  carbolic  acid  in  these  cases,  it  is 
not  likely  to  produce  a slough,  and  you  may  apply 
it  frequently — in  fact,  every  day,  if  you  desire  to  do 
so ; benefit  results,  but  the  effect  is  not,  in  my  opinion, 
so  permanent  as  that  derived  from  the  acid  nitrate  of 
mercury. 

In  very  bad  procidentia  good  may  be  effected,  but 
unfortunately  very  temporary,  by  dissecting  off  tri- 
angular or  elliptical  portions  of  the  mucous  mem- 
brane, and  bringing  the  edges  together  with  sutures 
of  horsehair  or  carbolised  catgut.  Care  must  be 
taken  in  performing  this  operation  not  to  remove 
more  than  mucous  membrane,  for  if  you  carry  your 
knife  into  the  sub-mucous  tissue,  you  will  get  very 
profuse  hemorrhage.  If  you  like  you  can  clamp 
portions  of  the  gut,  cut  them  away  and  use  the 
actual  cautery,  or  you  may  apply  a ligature ; I have 
tried  all  these  methods,  but  I can  only  say  that  I have 
achieved  very  partial  success ; the  patient  may  leave  the 
hospital  very  well,  and  you  may  congratulate  yourself 
upon  having  effected  a cure,  but  in  a few  months  the 
bowel  will  again  protrude,  in  all  probability,  as  badly 
as  ever. 

In  the  second  edition  of  this  work  I said,  “ Dr  Yan 
Buren,  of  New  York,  has  recommended  in  these  in- 
tractable cases  the  application  of  the  actual  cautery  to 
the  gut  in  spots  or  lines,  and  also  to  the  verge  of  the 
anus  over  the  external  sphincter  muscle,  so  as  to  get 
contraction  and  thus  support  the  bowel.  This  strikes 


168 


PROCIDENTIA  RECTI 


me  as  a very  good  suggestion,  and  I shall  certainly  try 
it  on  a case  where  other  means  have  failed.”  I have 
now  used  this  method  on  many  hospital  and  private 
patients  and  effected  permanent  cures. 

The  procidentia  in  the  adult  is  sometimes  very 
large ; I have  seen  it  in  a woman  larger  in  circum- 
ference than  the  foetal  head,  and  seven  or  eight  inches 
in  length. 

I have  had,  in  my  own  practice,  many  cases  of  pro- 
cidentia, in  which  there  was  a hernial  sac  in  the  pro- 
trusion, and  in  all  it  was  situated  anteriorly,  as  from 
the  anatomy  of  the  part,  of  course,  it  must  be;  you 
could  return  the  intestine  out  of  the  sac,  and  it  went 
back  with  a gurgling  noise. 

Directly  the  bowel  is  protruded  you  can  tell  that 
there  is  a hernia  also  present  by  the  fact  that  the 
opening  of  the  gut  is  turned  towards  the  sacrum ; when 
the  hernia  is  reduced  the  orifice  is  immediately  re- 
stored to  its  normal  position  in  the  axis  of  the  bowel. 
I have  seen  several  similar  cases  in  the  practice  of  my 
colleagues  at  St  Mark’s ; the  condition  is  therefore  not 
very  uncommon,  but  I have  never  found  it  in  children. 

In  very  old  and  bad  cases  of  procidentia  more  or  less 
incontinence  of  faeces  always  exists.  There  may  be 
two  reasons  for  this  symptom.  1st,  loss  of  tone  in  the 
sphincters ; the  frequent  protrusion  stretching  these 
muscles  so  that  they  lose  a great  deal  of  their  con- 
tractile power  ; and  2ndly,  the  mucous  membrane  gets 
so  altered  in  structure  as  to  lose,  in  a great  degree,  its 
natural  sensitiveness ; thus  when  faecal  matter  comes 
into  the  lower  part  of  the  rectum,  the  sphincters  are 
not  stimulated  to  action,  nor  is  the  patient  aware  of  its 
presence. 


PROCIDENTIA  RECTI 


169 


The  operation  by  the  hot  iron  or  Paquelin  cautery 
suggested  by  Dr  Yan  Buren  is  thus  performed  by  me. 
The  patient  is  put  under  the  influence  of  ether,  and  if 
the  part  be  not  down  it  can  be  readily  drawn  fully  out 
of  the  anus  by  the  vulsellum.  I then,  haying  the 
intestine  held  firmly  out,  with  the  iron  cautery  at  a dull 
red  heat,  make  four  or  more  longitudinal  stripes  from 
the  base  to  the  apex  of  the  protruded  intestine.  I take 
care  not  to  make  cauterisation  so  deep  towards  the 
apex  as  at  the  base,  because  near  the  apex  the  perito- 
neum may  be  close  beneath  the  intestine,  while  a deep 
burn  near  the  base  is  not  dangerous.  I take  care  to 
avoid  the  large  veins  which  can  be  seen  on  the  surface 
of  the  bowel.  If  the  procidentia  be  very  large  I make 
even  six  stripes.  I then  oil  and  return  the  intestine 
within  the  anus  ; having  done  this  I partially  divide 
the  sphincters  on  both  sides  of  the  anus  with  a sawing 
motion  of  the  hot  iron,  and  then  insert  a small  portion 
of  oiled  wool.  From  the  day  of  operation  I never  let  the 
patient  get  out  of  bed  for  anything ; the  motions  are  all 
passed  lying  down,  consequently  the  part  never  comes 
outside.  If  the  wounds  have  not  all  thoroughly 
healed  in  a month,  I continue  the  recumbent  position 
for  two  weeks  more,  by  which  time  it  very  rarely 
happens  that  all  is  not  healed.  The  patient  can  then 
arise  and  get  about,  but  still  for  some  time  I enjoin 
that  evacuation  of  the  motions  should  be  accom- 
plished lying  down.  The  reason  for  the  success  of 
the  treatment  is  simple  enough.  When  the  burns  are 
all  healed,  the  bowel,  by  contraction  of  the  longitu- 
dinal stripes  is  drawn  upwards,  and  circumferential 
diminution  also  takes  place.  In  these  cases  before 
operation  the  sphincter  muscles  have  quite  lost  power, 


170 


PROCIDENTIA  RECTI 


the  anus  is  large  and  patulous ; by  sawing  through  the 
anus  with  the  iron  the  muscles  contract  and  regain 
their  power,  the  patient  having  strength  to  cause  the 
anus  to  close  at  will,  and  even  to  some  extent  to 
squeeze  the  finger  when  introduced.  With  this 
method  of  treatment  I have  had  great  success,  many 
persons  being  quite  cured,  while  others  have  been 
greatly  benefited  so  as  to  be  able  to  work,  by  only 
wearing  a pad  of  cotton  wadding. 

In  a case  I had  with  Dr  Way,  of  Eaton  Square,  a lady 
who  had  for  years  suffered  from  a procidentia  recti  five 
inches  long  and  nearly  three  in  diameter,  a perfect 
cure  was  effected.  She  wrote  me  on  the  anniversary  of 
the  operation  to  say  the  bowel  had  never  come  down, 
though  she  walked  very  much  and  had  to  go  up  and 
down  flights  of  stairs  constantly.  I need  not  say  how 
grateful  she  was.  In  another  case  in  the  practice  of  Dr 
Woodhouse  of  Fulham,  in  which  several  operations  had 
been  performed  unsuccessfully  before  I saw  him,  and  the 
procidented  intestine  was  very  large,  a permanent  cure 
was  effected.  In  a very  bad  case  attended  by  the  late 
Mr  E.  Carr  Jackson  and  myself,  the  vessels  on  the  bowel 
were  so  large  that  great  bleeding  took  place  when  the 
cautery  was  applied,  and  ligatures  had  to  be  used. 
Secondary  haemorrhage,  to  an  extent  requiring  very 
careful  plugging,  also  occurred  when  the  sloughs 
separated.  ’This  patient  was  very  anaemic  through 
large  losses  of  blood  prior  to  the  operations,  and  he 
was  blanched  to  a dirty  white,  yet  he  thoroughly 
recovered,  and  the  bowel  has  never  again  protruded. 
This  patient  was  seen  quite  recently  and  remains  per- 
fectly well.  Several  hospital  cases  which  I have  had 
during  the  last  few  years  have  all  done  admirably, 


PROCIDENTIA  RECTI 


171 


though  some  have  required  much  care  and  watching 
for  months  after  the  operation.  Should  success  not 
attend  the  first  attempt  I should  be  quite  prepared 
to  repeat  the  operation,  with  every  hope  of  ultimately 
conquering  this  distressing  malady. 

Sometimes  when  a large  portion  of  the  bowel  comes 
down,  there  is  much  difficulty  experienced  in  return- 
ing it.  I have  found,  on  several  occasions,  that  the 
passing  up  the  bowel  of  a large  flexible  bougie,  so  as 
to  carry  before  it  the  upper  part  of  the  descended  gut, 
is  of  great  service ; gentle  taxis  should  at  the  same 
time  be  used,  and  in  this  manner  the  mass  can  generally 
be  returned.  When  the  gut  comes  down,  and  the 
patient  cannot  get  it  back  and  does  not  seek  assist- 
ance, it  gets  tightly  girt  about  by  the  sphincter,  great 
swelling  takes  place,  and  sloughing  may  ensue.  I 
have  seen  many  cases  of  this  kind,  but,  as  far  as  my 
experience  goes,  the  sloughing  is  partial,  and  only  the 
mucous  membrane  separates.  After  a few  days’  rest, 
with  the  buttocks  well  raised  to  favour  the  return  of 
blood,  the  part  can  be  replaced  and  considerable 
benefit  may  result.  The  only  case  I ever  saw  where 
anything  like  dangerous  or  deep  sloughing  took  place 
was  in  consultation  with  a medical  man  who  had  most 
assiduously  and  constantly  applied  a bladder  of  ice  to 
the  protruded  part,  and  this  had  so  much  favoured 
sphacelus  that  nearly  the  whole  mass  came  away,  and 
there  was  free  secondary  haemorrhage.  In  this  case 
the  sloughing  was  so  considerable  that  a very  intract- 
able stricture  resulted.  This  shows  the  necessity  of 
care  in  the  application  of  ice ; if  it  be  too  long  con- 
tinued, or  if  the  patient  be  old  or  of  feeble  constitution, 
dangerous  results  may  ensue. 


172 


PROCIDENTIA  RECTI 


I am  not  aware  of  any  internal  remedy  wliicli  is  of 
much  use  in  cases  of  procidentia,  but  small  and  fre- 
quent doses  of  opium  with  confection  of  black  pepper 
benefited  some  of  my  patients. 

A nasty  teasing  diarrhoea  is  very  commonly  present, 
and  there  is  often  a discharge  of  mucus,  which  keeps 
the  linen  always  damp,  and  adds  not  a little  to  the 
general  discomfort.  Powdered  acorns  I have  used  fre- 
quently with  advantage  for  the  diarrhoea.  The  acorns 
should  be  baked  and  grated  to  powder,  and  the  dose  is 
one  teaspoonful  in  half  a tumbler  of  milk  every  morning. 
I have  found  this  answer  better  than  either  gallic  or 
tannic  acid. 

The  frequent  and  bountiful  application  of  cold  water 
in  these  cases  is  to  be  most  strongly  recommended. 
Ordinary  astringent  lotions  are  not  more  useful  than 
plain  water. 


CHAPTER  XIII 


POLYPUS  RECTI 

This  disease  was  formerly  looked  upon  as  a very 
rare  one  ; recently,  however,  it  has  been  considered" 
rather  more  common,  and  it  is  supposed  that  in  times 
gone  by,  rectal  maladies  not  being  so  well  understood, 
many  cases  of  polypus  escaped  diagnosis.  At  a 
meeting  of  the  Pathological  Society  in  February,  1873, 
a gentleman  stated  that  he  had  seen  fifteen  cases  in 
twelve  months.  His,  I think,  must  be  a somewhat 
singular  experience.  I find  that  I have  noted  alto- 
gether 63  cases  without  complication,  as  having 
occurred  in  my  own  practice.  My  statistics  at  St 
Mark’s  Hospital  show  that  in  4000  cases  of  rectal 
disease  there  were  only  sixteen  of  polypus  without 
fissure . 

It  has  generally  been  believed  that  polypi  are  much 
more  frequently  found  in  children  than  in  adults  ; this 
has  not  been  the  case  in  my  experience,  as  36  existed 
in  children  under  fourteen  years  of  age,  and  27  in 
older  persons. 

By  the  word  “ polypus”  I must  be  understood  to 
mean  a pedunculated  growth  attached  to  the  mucous 
membrane  of  the  rectum,  and  generally  situated  not 
less  than  an  inch  from  the  anus.  I have  seen  them 
quite  two  inches  up  the  bowel,  but  only  occasionally 


174 


POLYPUS  RECTI 


more  than  that  distance.  In  the  majority  of  cases  the 
polypus  grows  from  the  dorsal  portion  of  the  rectum, 
but  I have  found  it  on  the  perineal  and  lateral  seg- 
ments. I think  some  surgeons  apply  the  term 
“ polypus  ” to  those  small  muco-cutaneous  joolypoid 
growths — which  are  so  often  found  at  the  upper  end 
of  a fissure — and  thus  swell  their  statistics. 

My  friend  Dr  Daniel  Molliere,  of  Lyons  (whose  work 
on  rectal  surgery  surpasses  all  others  in  its  pathology), 
says,  “ There  is  no  word  in  surgery  that  has  been 
more  abused  in  its  use  than  the  word  polypus,  espe- 
cially when  applied  to  tumours  of  the  rectum.  As  a 
matter  of  fact,  the  term  c polypus  of  the  rectum  ’ is 
used  to  describe  any  neoplasm,  no  matter  whether 
benign  or  malignant,  hard  or  soft,  provided  only  that  it 
adheres  to  the  rectum  by  a stalk  or  relatively  limited 
base.” 

Polypi  have  been  usually  described  as  of  two  kinds ; 
the  soft  or  follicular,  and  the  hard  or  fibrous — the  former 
being  found  in  children,  and  the  latter  in  grown-up 
persons.  I do  not  concur  in  the  statement  that  the 
soft  polypus  is  always  the  one  found  in  young  children, 
and  I am  of  opinion  that  the  true  fibrous  variety  is 
rare  even  in  the  adult.  In  fact,  this  rough  division  is 
very  far  from  the  pathological  truth,  for  the  true 
fibrous  polypus  in  its  anatomy  is  an  almost  perfect 
counterpart  of  the  fibroid  tumour  of  the  uterus.  In 
the  Hunterian  Museum  is  one  specimen  of  rectal 
polypus  arising  from  the  muscular  fibres  of  the  rectum, 
and  it  is  in  reality  a fibro -muscular  tumour,  or,  in  the 
nomenclature  of  Virchow,  a myoma.  The  few  I have 
seen  myself  have  been  nearly  as  large  as  an  English 
walnut;  they  creak  when  cut,  and  the  incised  surface 


POLYPUS  RECTI 


175 


is  of  a pale  colour.  The  peduncle  is  about  an  inch 
and  a half  long,  and  is  always  attached  above  the 
sphincters ; the  tumours  do  not  usually  appear  outside 
the  anus,  they  do  not  bleed,  but  when  they  do  pro- 
trude they  cause  pain,  irritation,  and  spasm,  and  often 
set  up  an  ulcer  in  the  bowel.  The  discharge  from 
them  is  of  a very  ichorous  and  ill-smelling  character. 
These  polypi  have  been  observed  and  minutely 
described  by  both  French  and  German  pathologists, 
and  are  considered  quite  exceptional  specimens  of  this 
form  of  tumour. 

The  polypi  usually  found  in  the  adult  are  smaller 
than  the  mucous  polypi  of  children ; they  are  multiple. 
I have  often  found  two  growing  from  opposite  sides  of 
the  rectum,  there  may  also  be  two  stems  with  one  head 
only.  The  pedicle  may  be  an  inch  or  a little  more  in 
length,  and  is  not  uncommonly  hollow ; the  polypi  are 
neither  very  hard  nor  soft,  and  are  easily  compressible, 
they  are  sometimes  cystic ; a large  vessel  runs  up  the 
stem,  in  some  cases  you  can  feel  it  pulsate. 

The  soft  follicular  polypus  of  children  is  no  doubt 
rarely  met  with  in  adults,  but  even  in  these  it  is  not  so 
rare  as  my  colleague,  Mr  Gowlland,  believes,  who  once 
stated  at  the  Medical  Society  that  there  were  only  two 
kinds  of  polypi,  “the  soft  and  the  hard.”  He  had 
evidently  not  consulted  the  writings  of  foreign  patho- 
logists, or  he  would  have  found  that  there  are  numbers 
of  different  forms.  The  soft  polypus  is  almost  always 
found  in  women,  and  thus  Dr  Routh  is  likely,  as  he 
says,  to  have  seen  a considerable  number.  The  stem 
is  remarkably  long  and  rather  slender. 

The  polypi  of  children  are  small  vascular  tumours, 
with  a peduncle  often  two  inches  long.  They  are 


176 


POLYPUS  RECTI 


about  tbe  size  of  a raspberry,  and  resemble  a small 
half-ripe  mulberry  more  than  anything  else ; they 
bleed  very  freely  at  times,  and  occasion  in  the  young 
great  debility.  They  are  said  to  be  either  hyper- 
trophies of  the  glands  of  Lieberkiihn,  or  of  the  mucous 
follicles  of  the  rectum.  They  may  be  dangerous  when 
high  up  by  occasioning  intussusception  of  the  bowel, 
with  total  obstruction  and  death.  When  the  peduncle 
is  more  than  an  inch  in  length  they  usually  protrude  at 
stool,  and  require  to  be  returned  after  the  bowels  are 
relieved.  They  are  sure  to  be  described  by  the  child’s 
mother  as  piles,  or  as  “ the  body  coming  down.” 

The  peduncle  is  sometimes  so  slender  that  it  breaks 
on  very  slight  traction,  and  I dare  say  many  polypi 
become  detached  when  the  child  is  straining  or  pass- 
ing a hard  motion,  and  are  thus  spontaneously  cured. 

A most  valuable  and  original  account  of  polypi  in 
children,  by  the  late  Dr  Bathurst  Woodman,  and 
founded  on  his  experience  at  the  North-Eastern  Hos- 
pital for  Children,  may  be  found  in  the  c Medical  Press 
and  Circular,’  May  5th,  1875.  He  names  five  kinds 
of  polypi — 1,  the  soft  or  gelatinous;  2,  the  cystic; 
3,  the  papillomatous ; 4,  the  dermoid ; 5,  the  sarco- 
matous. Dr  Woodman  states  that  the  most  common 
variety  in  children  is  the  hard  polypus  (I  must  say 
that  such  has  not  been  my  experience),  and  that  “ the 
children  of  arthritic  parents,  and  those  suffering  from 
the  syphilitic,  tuberculous,  and  cancerous  cachexias  are 
most  liable  to  these  affections.” 

From  the  polypus  of  the  adult  I have  often  seen 
abscess,  ulcer  or  fissure,  and  fistula  arise.  A short 
time  since  a patient  was  sent  to  me  with  a fistula 
complete  and  dorsal ; the  probe  passed  readily  through 


POLYPUS  EECTI 


177 


it  into  the  bowel.  On  introducing  my  finger  I found 
the  internal  opening  very  large,  a hard  polypus  as  big 
as  a marble  projected  into  it ; the  stem  was  quite  half 
an  inch  long,  and  was  attached  near  the  promontory 
of  the  sacrum.  I have  seen  on  post-mortem  examina- 
tions in  both  adults  and  children,  full-sized  polypi 
attached  as  high  as  the  sigmoid  flexure  of  the  colon, 
and  also  in  the  colon  itself ; they  cause  diarrhoea  and 
may  bring  on  obstruction  of  the  bowel  by  setting  up 
inflammation,  which  occasions  paralysis  of  the  mus- 
cular coat  of  the  intestine.  When  fissure  exists  with 
polypus,  the  removal  of  the  polypus  and  gentle  dilata- 
tion will  cure  t>oth  maladies. 

The  diagnosis  of  polypus  has  been  stated  to  be 
difficult.  I cannot  myself  see  why  any  difficulty 
should  arise.  The  history  of  the  case  and  the  sym- 
ptoms will  usually  lead  you  to  suspect  what  the  disease 

is,  and  if  you  are  careful  to  administer  an  injection 
and  thoroughly  search  the  bowel  you  must  feel  or  see 

it.  When  a polypus  has  a long  pedicle  it  is  apt  to  slip 
away  from  the  finger,  but  even  then  the  peduncle  can 
be  readily  felt  at  its  point  of  attachment  to  the  rectum. 

The  general  symptoms  in  children  are ; — frequent 
desire  to  go  to  stool,  accompanied  by  tenesmus,  occa- 
sional bleeding  with  discharge  of  mucus,  and  a fleshy 
mass  protruding  from  or  appearing  at  the  anus  when 
the  bowels  are  acting. 

It  is  possible  to  mistake  this  disease  for  internal 
piles,  procidentia  recti,  or  dysentery.  An  examination 
after  an  injection  will  clear  up  the  doubt  in  the  first 
two  cases ; in  the  last,  the  presence  of  fever,  the 
abdominal  pain,  and  the  appearance  of  the  motions 
are  sufficiently  distinctive  indications. 


12 


178 


POLYPUS  RECTI 


In  the  adult  the  history  carefully  inquired  into  may 
be  found  peculiar.  The  patient  will  tell  you  that  with- 
out any  previous  marked  discomfort  in  the  rectum,  he 
all  at  once  discovered  that  a substance  protruded  on 
going  to  the  closet.  This  is  characteristic  of  the 
malady ; until  the  peduncle  becomes  long  enough  to 
allow  of  the  polypus  being  extruded  or  grasped  by  the 
external  sphincter,  but  little  or  no  inconvenience  is  felt, 
therefore  the  onset  of  the  disease  is  considered  by  the 
patient  as  sudden ; this  is  quite  different  from  the 
history  of  haemorrhoids. 

I cannot  at  all  say  why  these  growths  should  arise ; 
they  are  not  often  connected  with  haemorrhoids  or  any 
other  diseases  of  the  rectum  save  fissure  and  intussus- 
ception. I have  not  even  observed  that  constipation, 
that  potent  factor  of  bowel  affections,  obtains  in  these 
cases.  I will  relate  a few  cases  of  polypus,  and  then 
say  a word  or  two  about  treatment. 

Thos.  B — , set.  4,  seen  at  the  Farringdon  Dispensary,  October  27th, 
1862.  For  more  than  twelve  months  has  had  what  was  supposed  to  be 
prolapsus  of  the  bowel ; he  lost  a good  deal  of  blood  at  times,  and  was 
very  feeble  and  ansemic.  After  an  injection  there  came  down  to  the 
anus  a spongy,  irregular- shaped,  bleeding  mass,  fully  as  large  as  a 
medium-sized  walnut ; it  felt  soft  but  not  gelatinous.  A tolerably  long 
pedicle  connected  it  with  the  anterior  wall  of  the  rectum.  I applied 
a ligature  and  cut  the  polypus  off.  He  was  ordered  an  astringent 
draught  to  confine  the  bowels  for  a few  days.  November  1st. — He 
took  a dose  of  castor  oil  and  the  ligature  came  away  on  the  bowels 
acting.  There  was  no  bleeding.  Discharged  cured. 

Jane  H — , set.  7,  brought  to  St  Mark’s  Hospital,  October,  1864.  Her 
mother  said  that  something  came  down  when  the  bowels  acted,  and  she 
lost  much  blood ; she  was  obliged  to  put  the  substance  back  again. 
After  an  injection  two  tumours  made  their  appearance,  and  I at  first 
thought  it  was  a case  of  haemorrhoids ; but  on  closer  examination, 
passing  my  finger  into  the  rectum,  I found  that  they  were  polypi,  arising 
by  two  peduncles  from  quite  an  inch  and  a half  up  the  bowel.  One 


POLYPUS  EECTI 


179 


appeared  to  be  attached  dorsally,  and  the  other  laterally.  I applied 
two  ligatures  and  snipped  off  the  growths.  In  three  days  the  ligatures 
came  away,  and  she  was  soon  quite  well. 

Henry  de  0 — , admitted  into  St  Mark’s,  March,  1866.  He  was  six 
years  old,  and  looked  a very  feeble  delicate  boy.  For  two  or  three 
years  he  had  lost  blood  at  stool,  and  latterly  something  had  protruded 
after  an  evacuation ; it  had  to  be  returned  by  pressure.  He  had  taken 
a quantity  of  medicine,  and  been  treated  at  several  public  institutions. 
After  an  injection  a dark-coloured,  very  vascular  polypus  came  into 
view ; it  had  a well-defined,  rather  thick  neck.  I applied  a ligature 
and  cut  through  the  pedicle  ; the  tumour  was  about  the  size  of  a rasp- 
berry. The  thread  separated  in  five  days,  and  there  was  no  haemorrhage. 
I kept  him  under  observation  some  time,  giving  him  tonics ; he  was 
ultimately  discharged  perfectly  recovered. 

Hugh  L — , set.  9,  a weak  and  irritable  boy,  emaciated  and  bloodless, 
suffers  from  cough.  His  mother  says  he  has  been  troubled  for  five 
years  at  least  with  his  bowel  coming  down  whenever  he  went  to  the 
closet.  He  returned  it  himself  by  pressure.  He  had  been  taken  to 
medical  men,  and  also  to  hospitals,  and  she  had  been  told  that  it  was  a 
weakness  of  the  bowel,  and  had  used  ointments  and  lotions  for  it.  The 
loss  of  blood  he  had  sustained  lately  had  been  very  severe.  He  did  not 
suffer  any  pain.  When  I first  saw  him  his  mother  said  “ his  body  ” 
would  come  down  if  he  stooped  and  strained  a little,  and  on  his  doing 
so  a round,  vascular,  bright-red,  villous  body,  bleeding  freely,  was  seen 
outside  the  anus.  It  was  not  at  all  painful  to  the  touch.  I found  that 
it  was  connected  with  the  bowel  just  above  the  internal  sphincter  by  a 
pedicle  of  pale  colour,  at  least  two  inches  long.  I applied  a silk  liga- 
ture and  ordered  him  a little  aromatic  confection  to  confine  his  bowels. 
In  three  days  the  ligature  separated  on  action  taking  place.  I then 
prescribed  for  him  some  iron  and  cod-liver  oil.  In  a fortnight  they 
brought  him  again,  saying  that  another  substance  had  made  its  appear- 
ance, and,  sure  enough,  on  his  straining,  a tumour,  almost  precisely 
similar  to  the  former  one,  protruded  from  the  anus.  To  this  also  I 
applied  a ligature.  When  I saw  him  at  the  end  of  a week  I adminis- 
tered an  injection  to  see  if  there  were  any  more  polypi,  but  I found 
none,  so  discharged  him  as  cured. 

Duncan  J — , set.  18,  came  to  St  Mark’s  in  1867.  His  health  was 
generally  good.  For  twelve  months  he  has  had  something  protrude 
from  the  anus  on  visiting  the  water-closet,  and  he  had  lost  a quantity 
of  blood.  It  retracted  spontaneously  on  his  rising  up  after  the  action. 
He  has  been  under  the  care  of  many  physicians  and  surgeons,  and  has 
always  been  treated  for  bleeding  piles.  He  has  a pain  of  a dragging 


180 


POLYPUS  RECTI 


burning  character  in  the  rectum,  but  it  is  not  severe.  After  an  injec- 
tion a large  (the  size  of  a walnut)  vascular,  velvety-looking  polypus 
appeared  at  the  verge  of  the  anus.  The  pedicle  was  rather  thin,  and 
not  so  long  as  usual.  I held  it  with  a vulsellum  while  the  house-surgeon 
applied  a ligature ; this  was  pulled  so  tight  that  it  cut  the  peduncle  at 
once.  I was  apprehensive  of  bleeding,  and  so  kept  him  lying  down  in 
the  out-patients’  room  for  a couple  of  hours,  when,  finding  there  was 
no  haemorrhage,  I sent  him  home.  In  a week  he  came  and  said  he  was 
quite  well. 

Martha  H — , set.  25,  married ; no  children  ; several  miscarriages ; 
admitted  into  St  Mark’s  1865.  She  had  one  perineal  haemorrhoid  and 
a dorsal  fibrous  polypus,  the  size  of  a hazel-nut.  The  polypus  had  a 
shortish  broad  pedicle ; it  was  situated  above  the  internal  sphincter, 
and  I found  some  difficulty  in  applying  a ligature.  She  left  the  hospital 
well. 

Mr  James  B — , aet.  37,  was  sent  to  me  by  a medical  man  who  thought 
he  was  suffering  from  piles.  After  an  injection  a polypus  came  down, 
resembling  much  that  found  in  children,  but  it  was  firmer  and  not  so 
vascular ; it  was  about  the  size  of  a raspberry.  I placed  a ligature  on 
the  stem  and  cut  it  off.  This  gentleman  did  not  rest,  as  I advised  him 
to  do,  for  a few  days,  and  he  had  an  abscess  form  a week  after  the 
separation  of  the  ligature. 

A lady,  set.  46,  who  had  been  supposed  to  be  suffering  from  some 
uterine  affection,  was  sent  to  me  by  Dr  Priestley.  He  had  found  on 
examination  that  the  patient’s  symptoms  were  due  to  a polypus  of  the 
rectum  ; this  was  easily  felt  from  the  vagina.  I removed  the  polypus, 
and  the  patient  soon  recovered. 


These  cases  of  polypus  forcibly  illustrate  the  desira- 
bility of  always  giving  an  enema  before  making  an 
examination,  as  it  is  only  by  seeing  the  patient  just 
after  the  bowels  have  acted  that  you  can  make  certain 
of  your  diagnosis. 

The  only  treatment  to  be  recommended  is  the 
removal  of  the  growth.  I do  not  think  it  safe  either  to 
cut  or  tear  polypi  off,  as  troublesome  arterial  hsemor- 
rhage  may  ensue.  I have  seen  them  bleed  very  freely 
indeed,  and,  as  they  are  attached  at  some  distance 


POLYPUS  EECTT 


181 


from  the  anus,  it  would  be  by  no  means  easy  to  place 
a ligature  upon  the  bleeding  vessel. 

I have  used  the  clamp  and  actual  cautery  twice,  and 
it  answered  very  well,  but  it  is  rather  a formidable 
proceeding,  the  idea  of  hot  irons  frightening  the 
patient,  although  really  the  application  is  painless,  as 
also  is  the  ligature;  the  latter  has  the  advantage  of 
being  always  at  hand.  The  simplest  method,  however, 
is  to  seize  the  peduncle  close  to  its  base  with  the 
German  catch-torsion  forceps  and  gently  twist  the 
polypus  around  until  it  comes  away.  There  is  no 
danger  of  haemorrhage,  no  pain,  and  scarcely  any 
necessity  for  resting  more  than  one  day. 

If  a ligature  be  used,  I think  it  is  very  desirable  that 
the  patient  should  rest  until  it  separates,  and  I usually 
order  a mild  astringent  draught  to  keep  the  bowels 
confined  for  three  days,  then  I administer  an  aperient, 
and  on  relief  taking  place  the  ligature  comes  away. 
In  two  cases  I have  seen  abscesses  follow  where  much 
exercise  had  been  taken. 


CHAPTER  XIV 


PRURITUS  ANI 

Pruritus  ani,  or,  as  it  may  be  well  called,  painful 
itching  of  the  anus,  is  a most  distressing  malady.  I 
have  often  heard  a patient  say  that  his  or  her  life  was 
rendered  almost  unendurable  by  it.  In  fact,  one  very 
nervous  invalid  told  me  that  unless  he  had  obtained 
relief  he  believed  that  he  should  have  gone  out  of 
his  mind.  It  is  very  intractable,  but  I am  confident 
that  it  is  always  curable  if  the  patient  will  strictly, 
patiently,  and  persistently  follow  the  advice  of  his 
medical  attendant. 

The  disorder  is  frequently  induced,  or  at  all  events 
kept  up,  by  habits  of  too  free  eating  and  drinking,  and 
its  successful  treatment  therefore  calls  for  a consider- 
able amount  of  self-denial  on  the  part  of  the  patient ; 
and  thus  it  often  happens  that  as  soon  as  the  sufferer 
gets  relieved  he  forgets  all  his  prudent  resolutions 
and  relapses  into  his  old  way  of  life — a step  which  is 
pretty  certain  to  result  in  the  return  of  his  enemy  in  full 
force.  He  then  usually  blames  his  doctor,  very  rarely 
himself,  and  either  gives  up  in  despair  all  hope  of  cure, 
or  seeks  new  advice,  so  that  the  affection  comes  to  be 
considered  as  not  only  an  exceedingly  troublesome  one, 
but  almost  incurable.  I can  truly  state  that  I have 
rarely,  if  ever,  failed  to  cure  a patient  who  adhered 


PftURITUS  AN  I 


183 


rigidly  to  my  directions ; and  when  a person,  the  sub- 
ject of  bad  pruritus,  comes  to  me,  I always  say, — “ Un- 
less you  intend  to  conform  most  religiously  to  my 
directions  as  long  as  I think  necessary,  I cannot  cure 
you,  and  I had  much  rather  that  you  consulted  some 
other  surgeon.”  Although,  as  I have  said,  free  living 
often  induces  pruritus,  I have  met  with  many  cases  in 
very  abstemious  persons ; I have  seen  a most  ascetic 
clergyman  suffer  dreadfully,  and  I have  had  under  my 
care  a lady  who  nearly  all  her  life  has  been  a total 
abstainer  from  alcohol,  and  is  a remarkably  small  eater, 
yet  she  has  been  quite  a martyr  to  this  complaint. 

The  irritation  in  the  majority  of  cases  is  worse  at 
night,  especially  when  the  patient  gets  warm  in  bed, 
so  that  often  the  greater  part  of  the  night  is  rendered 
sleepless  and  inexpressibly  wretched ; towards  the 
morning,  irritable  and  worn  out,  he  falls  off  into  a 
fitful  slumber,  from  which  he  often  awakens  himself  by 
scratching  ; this  of  course  makes  the  part  more  or  less 
raw,  and  materially  adds  to  his  discomfort  in  the  day- 
time. I need  scarcely  say  that  the  more  the  sufferer 
scratches  the  worse  he  makes  himself,  although  it  is 
very  difficult  indeed  to  avoid  seeking  the  temporary 
relief  it  affords.  Many  persons  have  told  me  they 
would  infinitely  prefer  decided  pain  to  the  dreadful  and 
constant  itching  they  have  to  endure,  which  really, 
after  a time,  becomes  pain  of  a most  sickening  cha- 
racter. Excitable  people  are  often  greatly  troubled  in 
the  day  as  well  as  at  night,  the  itching  setting  in  badly 
after  exercise  or  on  leaving  the  cold  air  and  coming 
into  a warm  room. 

Doubtless  there  are  many  cases  of  pruritus  for  which 
we  are  unable  to  assign  any  cause,  and  it  may  then  be 


184 


PRURITUS  ANI 


considered  as  a pure  neurosis  ; but  usually  it  is  possible 
to  discover  some  reason  for  the  irritation  in  derange- 
ment of  other  organs.  These  causes  may  be  mentioned 
— liver  affections,  internal  haemorrhoids,  constipation 
anything  causing  pressure  upon  the  haemorrhoidal 
veins  so  as  to  retard  the  return  of  blood  from  the 
rectum,  disorders  of  the  stomach  induced  by  errors  in 
diet,  latent  gout,  uterine  diseases,  and  we  must  not 
forget  parasites  ; as  vegetable  growths,  pediculi  similar 
to  those  found  on  the  pubes  ; and  ascarides. 

It  is  generally  stated  that  there  is  very  little  altera- 
tion in  the  aspect  of  the  part  affected,  and  that  nothing 
is  to  be  observed  beyond  a roughened,  thickened,  and 
more  rugose  state  of  the  skin  just  around  the  anus. 
This  I think  is  by  no  means  usually  the  case  ; some- 
times there  is  a distinctly  eczematous  rash,  the  part 
being  always  moist  from  exudation  ; at  others  there  is 
a dry  rugose  condition,  with  bright  redness  consequent 
upon  scratching ; occasionally  there  are  a quantity  of 
minute  scales  to  be  seen,  forming  irregular  rings ; often 
cracks  are  seen  radiating  from  the  anus,  and  even 
extending  up  to  the  sacrum,  but  what  I consider  the 
characteristic  condition — which  may  always  be  noticed 
when  the  disease  is  severe,  and  has  lasted  for  any 
length  of  time — is  the  loss  of  the  natural  pigment  of 
the  part.  To  such  an  extent  does  this  often  obtain, 
that  patches  around  the  anus,  extending  backwards  as 
far  as  the  sacrum  and  forwards  to  the  scrotum,  are  of 
a dull  dead  white,  the  skin  looking  more  like  very 
white  parchment  than  natural  integument,  and  if  you 
pinch  it  up  you  will  feel  that  it  has  lost  its  normal 
elasticity.  I have  seen  a similar  condition  induced  by 
genital  pruritus  in  women. 


PRURITUS  ANI 


185 


When  considering  a case  as  to  the  question  of  treat- 
ment, it  is  always  important  to  discover  the  cause  of 
the  irritation ; particular  articles  of  diet  or  drink  affect 
some  persons  in  a remarkable  manner.  I once  had  a 
patient  who  invariably  got  an  attack  of  pruritus  from 
eating  lobster  or  crab,  and  of  these  shellfish  he  was 
inordinately  fond,  but  rarely  dared  to  indulge  his  taste. 
I have  seen  a similar  result  from  eating  salmon. 
Another  of  my  patients  was  sure  to  suffer  if  he  drank 
any  quantity  of  champagne  or  ale,  and  the  irritation 
once  started  was  very  difficult  to  arrest.  There  is  but 
little  doubt  that  excesses  at  table,  combined  with  a 
want  of  active  exercise,  are  not  only  a predisposing  but 
also  an  exciting  cause.  Excessive  smoking  is  another 
excitant  of  the  disorder ; I have  seen  several  instances 
(where  patients  had  a tendency  to  the  malady)  of  over- 
indulgence  in  smoking  being  followed  immediately  by 
an  attack  of  pruritus. 

Spare  no  pains  to  investigate  closely  the  habits  of 
your  patient.  Stout  plethoric  people  should  be  put  on 
a rather  low  diet ; they  should  avoid  all  rich  and  highly 
seasoned  dishes,  eat  but  little  meat,  and  take  fish, 
poultry,  vegetables,  and  ripe  fruits.  Interdict  both 
beer  and  spirits,  and  restrict  the  drinking  to  a little 
light  sherry  or  claret  and  Vichy  or  seltzer  water. 
Coffee  should  be  given  up,  weak  tea  or  cocoa  being 
taken  at  breakfast.  Enjoin  a walk  of  three  or  four 
miles  daily,  and,  if  possible,  at  such  a speed  as  to  in- 
duce slight  perspiration ; let  the  patient  take  a sponge 
bath  every  morning,  a warm  or  Turkish  bath  once  in 
the  week,  and  every  night  when  retiring  to  bed  wash 
the  anus  and  parts  around  with  warm  water  and  tar 
or  Castile  soap.  If  the  bowels  are  at  all  confined  the 


186 


PRURITUS  ANI 


following  prescription  will  be  found  beneficial : — 
Magnes.  Sulpb.  3j,  Magnes.  Carb.  pond.  gr.  v,  Vini 
Colchici  niv,  Syrupi  Sennae  3j,  Tinct.  Oardam.  comp. 
5ss,  ex  Inf.  Chiratae  gj,  twice  or  thrice  in  the  day;  and 
I also  often  order  Pil.  Plummer,  gr.  ij,  Pil.  Rhei  comp, 
gr.  iij,  to  be  taken  every  other  night  for  a week.  The 
mineral  waters  of  Carlsbad,  Friedrichshall,  Vichy, 
Hunyadi  Janos,  Pullna,  &c.,  are  good  remedies,  and  I 
frequently  employ  them. 

After  the  washing  at  night  let  the  patient  apply 
this  ointment  freely : Hydrarg.  Subchlor.  gr.  x,  Ung. 
Sambuci  3j ; or  this  lotion,  which  is  very  efficacious 
in  allaying  irritation : Sodas  Biboratis  3ij,  Morphias 
Hydrochlor.  gr.  xvj,  Acidi  Hydrocyanic,  dil.  gss 
Glycerinae  gij,  Aq.  ad  gviij.  Misce.  Dab  the  part  fre- 
quently. A chloroform  pomade  made  thus  is  often 
useful : Chloroform  51J , Glycerinae  gss,  Ung.  Sambuci 
giss.  Misce.  A lotion  of  borax  with  colchicum,  a 
saturated  solution  of  borax,  the  Ung.  Boracis  c. 
Vaseline  (gr.  x,  ad  53),  the  sulphide  of  calcium 
internally  and  externally,  as  recommended  by  Hebra, 
a pad  of  Tenax,  are  other  remedies  that  may  be  tried. 
Sir  Benjamin  Brodie  had  much  success  from  the  white 
precipitate  ointment.  The  following  prescription  of 
the  late  Mr  Startin  has  been  of  great  service  to  many 
patients  suffering  from  eczema.  I have  seen  a bad 
case  cured  in  forty-eight  hours  by  its  application 
alone  : Liquoris  Carbonis  Detergent.  (Wright’s),  Glyce- 
rinae, anagj,  Zinci  Oxidi,  Pulv.  Calamin.  prep.,  ana  gss, 
Pulv.  Sulph.  precip.  5SS,  Aquae  purae  ad  gvj.  Misce. 
The  part  affected  to  be  painted  thickly  over  once  or 
twice  daily  and  allowed  to  dry.  Lastly,  I must  not 
omit  to  mention  carbolic  acid,  with  glycerine  or  water, 


PRURITUS  ANI 


187 


as  being  very  useful,  and  also  prophylactic,  after  other 
treatment  has  succeeded. 

All  remedies  may  for  a time  be  disappointing,  and 
in  long-standing  cases  you  must  be  prepared  to  alter 
your  prescriptions  until  you  find  what  best  suits  your 
patient.  In  old  and  feeble  persons  the  combination 
of  the  sulphates  of  iron  and  magnesia  with  dilute  sul- 
phuric acid  and  infusion  of  quassia  often  does  good ; 
with  it  I have  cured  a number  of  elderly  people  whose 
lives  were  embittered  by  long-continued  itching.  Often 
in  them  the  parts  are  quite  raw,  and  discharge  an 
ichorous  irritating  fluid.  The  tonic  and  laxative 
mixture  above  mentioned  and  the  borax  lotion,  with 
great  attention  to  washing  the  part  with  warm  water 
and  Castile  soap,  have  usually  been  followed  with  great 
benefit  and  ultimate  cure. 

When  you  have  made  up  your  mind  that  the  essence 
of  the  disease  is  in  the  nervous  system,  as  I think  it 
often  is,  particularly  in  spare  and  delicate,  excitable 
people,  you  should  give  arsenic  and  quinine  freely,  and 
be  prepared  to  push  them  to  their  physiological  effect. 
They  may  be  taken  separately  or  combined.  I have 
rarely  failed  to  cure  this  cJass  of  case  by  perseverance 
in  these  remedies ; at  the  same  time,  of  course, 
using  local  means  to  allay  irritation.  In  obstinate, 
old-standing  cases  I usually  commence  the  treatment 
by  rubbing  the  parts  thoroughly  with  a solution  of 
nitrate  of  silver,  9ij  to  the  ounce ; this  softens  the 
skin  and  induces  a more  healthy  action  and  secretion. 
At  times  I have  found  Condy’s  fluid,  undiluted,  useful 
for  the  same  purpose  : it  should  be  applied  twice  or 
oftener  in  the  week. 

The  disorder  is  not,  by  any  means,  so  common  in 


1 88 


PRURITUS  ANI 


women  as  in  men,  nor  is  it  frequently  met  with  in 
young  persons ; but  one  of  the  most  obstinate  cases  I 
ever  had  occurred  in  a delicate  lad  of  seventeen.  There 
did  not  appear  to  be  any  ascertainable  cause  for  the 
irritation,  and  he  was  eventually  cured  by  Liquor 
Potassse  Arsenitis  in  full  doses  and  cod-liver  oil.  I 
had  once  a very  intractable  case  in  a man  nearly  eighty 
years  of  age,  who  was  an  inmate  of  the  Bookbinders’ 
Almshouses  at  Kingsland ; it  resisted  all  remedies  for 
some  time,  but  eventually  yielded  to  arsenic  internally 
and  the  strong  caustic  solution  frequently  applied.  In 
women  the  uterine  functions  should  be  attended  to ; 
and  I have  frequently  found  the  citrate  of  iron,  quinine, 
and  strychnine  very  advantageous. 

I have  met  with  a good  many  examples  of  latent  gout 
as  a cause  of  pruritus  ani. 

A gentleman  was  under  my  care  some  time  ago 
who  had  often  suffered  from  pruritus,  and  always  got 
rid  of  it  when  gout  attacked  him,  and  he  was  free  for 
some  time  afterwards.  Here  diet  is  a most  important 
element  in  the  treatment.  I think  the  irritation  is  best 
allayed  by  a strong  solution  of  bicarbonate  or  bisulphite 
of  soda  frequently  applied  in  a poultice.  I have  formed 
a good  opinion  of  the  usefulness  of  lithia  water  and  the 
effervescing  citrate  of  lithia.  In  some  cases,  where 
the  irritation  is  very  severe,  colchicum  with  alkalies 
answers  best,  but,  if  it  can  be  managed,  a course  of 
waters  at  Baden-Baden,  Ems,  or  Carlsbad,  will  be  found 
most  beneficial. 

I have  a very  excitable  nervous  patient  who  fre- 
quently gets  an  attack  of  pruritus  when  he  is  mentally 
overworked  or  irritated,  and  in  this  and  similar  cases 
I have  found  the  bromide  of  potassium  very  advan- 


PRURITUS  ANI 


189 


tageous,  and  I have  combined  with  this  ten  or  fifteen 
grains  of  the  hydrate  of  chloral.  This  mixture  taken 
at  bedtime  generally  ensures  a fair  night.  An  ex- 
tended experience  in  this  class  of  cases  has  induced  me 
to  think  most  highly  of  the  bromide  of  potassium  and 
chloral  in  combination.  In  alternation  with  the  chloral 
I have  seen  great  advantage  result  from  the  Succus 
Conii  in  full  doses  (one  to  two  drachms  given  three 
times  in  the  day) ; to  this  may  be  added  cod- liver  oil 
after  meals,  by  which  means  I think  you  may  repair 
nerve-tissue  and  induce  a more  regular  distribution  of 
nerve-force.  I am  fully  convinced  that  the  more  you 
treat  pruritus  ani  as  a general  disease  the  more  suc- 
cessful you  will  be  ; the  difficulty  in  curing  it  has  arisen 
in  great  measure  from  its  having  been  considered  as 
merely  a local  affection,  and  only  local  means  having 
been  applied  for  its  relief. 

In  the  treatment  of  pruritus  ani  it  is  well  to  avoid 
the  internal  administration  of  opium  in  any  form  ; you 
may  procure  a night’s  rest  by  its  use,  but  you  pay 
dearly  for  it  afterwards  in  an  increase  of  the  disorder. 
When  the  irritation  is  so  great  that  the  patient  is  quite 
worn  out  for  want  of  rest,  I have  for  years  past  recom- 
mended the  introduction  into  the  anus  at  bedtime  of  a 
bone  plug,  shaped  like  the  nipple  of  an  infant’s  feeding 
bottle,  with  a circular  shield  to  prevent  it  from  slipping 
into  the  bowel ; the  nipple  should  be  about  an  inch  and 
a half  in  length  and  as  thick  as  the  end  of  the  fore- 
finger. This  is  most  efficient  in  preventing  the  noc- 
turnal itching  ; a good  night’s  rest  is  almost  sure  to 
result  from  its  use,  but  I advise  it  to  be  worn  only  every 
other  night.  I presume  that  it  benefits  by  exercising 
pressure  upon  the  venous  plexus  and  filaments  of 


190 


PRURITUS  ANI 


nerves  close  to  the  anus.  The  idea  of  this  plug  oc- 
curred to  me  from  several  of  my  patients  telling  me 
that  the  only  way  they  could  obtain  relief  and  sleep, 
when  the  itching  was  very  bad,  was  by  introducing  the 
end  of  the  forefinger  into  the  anus,  and  making  pressure ; 
this  instantly  arrested  the  irritation. 

When  pruritus  is  accompanied  by  internal  haemor- 
rhoids, their  removal  almost  always  cures  the  itching ; 
this  result  was  well  shown  in  a very  bad  case  operated 
upon  by  me  in  the  practice  of  Mr  Gervis,  of  Haverstock 
Hill.  The  irritation  had  been  present  for  a long  while, 
and  it  had  resisted  all  kinds  of  treatment,  but  yielded 
when  the  piles  were  got  rid  of. 

Pruritus  caused  by  a parasitic  vegetable  growth  is 
readily  cured  by  the  application  of  sulphur  ointment ; 
or,  what  is  much  cleaner,  and  equally  efficacious,  a 
lotion  of  sulphurous  acid  of  the  strength  of  one  part 
to  six  of  water. 

I had  some  time  ago  in  an  adult  a very  obstinate 
case  of  anal  irritation,  caused  by  ascarides.  I really 
did  not  expect  these  to  be  the  origin  of  the  malady,  but 
I happened  to  see  one  of  the  worms  just  at  the  orifice ; 
a brisk  purge,  and  a few  injections  of  a solution  of  iron 
freed  the  patient  of  the  parasites  and  the  pruritus 
also.  It  is  always  well  to  bear  in  mind  the  possibility 
of  these  causes  of  the  disorder. 


CHAPTER  XY 


FISSURE  AND  PAINFUL  IRRITABLE  ULCER  OF  THE  RECTUM 

This  is  an  excessively  painful  and  by  no  means  un- 
common affection ; it  is  more  frequently  found  in 
women  than  in  men,  although  not  rare  in  the  latter. 
I have  seen  fissure  in  a baby  in  arms,  and  in  an  old 
woman  of  eighty,  in  whom  it  was  associated  with  an 
impaction.  By  far  the  most  usual  position  of  fissure 
is  dorsal  or  nearly  dorsal,  although  it  may  be  anterior 
or  lateral.  It  may  be  brought  about  by  an  injury  or 
tearing  of  the  delicate  mucous  membrane  at  the  verge 
of  the  anus ; it  may  therefore  be  caused  by  straining, 
or  by  the  passage  of  very  dry,  hard  motions  ; sometimes 
it  follows  severe  diarrhoea ; it  is  frequently  the  sequel 
of  a confinement,  and  the  accompaniment,  and  occa- 
sional result,  of  polypus.  The  origin  of  many  fissures 
is  syphilis. 

As  a rule  patients  suffering  from  fissure  of  the  rec- 
tum imagine  that  their  symptoms  are  due  to  haemor- 
rhoids  ; they  tell  you  that  they  have  a discharge  of 
blood  and  matter,  a swelling  outside  the  bowel,  and 
pain  at  stool,  and  they  believe  they  have  piles.  Unfor- 
tunately, not  infrequently  the  medical  attendant  is 
satisfied  with  the  patient’s  diagnosis,  and  treats  the 
case  as  one  of  external  haemorrhoids. 

I should  say  generally  that  when  a patient  complains 


192 


FISSURE  OF  THE  ANUS 


of  great  pain  on  defaecation,  it  is  not  piles  lie  is 
suffering  from,  and  certainly  not  uncomplicated  piles. 

In  fissure  the  pain  on  the  bowels  acting  is  more  or 
less  acute ; some  describe  it  as  like  tearing  open  a 
wound,  and  doubtless  it  is  of  a very  excruciating 
character.  I have  known  patients  who  for  hours  could 
not  bear  to  stir  from  one  position,  the  least  movement 
causing  an  exacerbation  of  the  pain.  This  agony 
induces  the  sufferer  to  postpone  relieving  the  bowels 
as  long  as  possible,  the  result  being  that  the  motion 
becomes  desiccated  and  hardened,  and  inflicts  more 
grievous  pain  when  at  last  it  has  to  be  discharged. 
After  action  of  the  bowels,  the  pain  may  in  a short 
time  entirely  cease,  and  not  return  at  all  until  another 
evacuation  takes  place,  but  often  it  continues  very  se- 
vere and  of  a burning  character,  or  it  is  of  a dull  heavy 
character,  and  accompanied  by  throbbing,  which  lasts 
for  hours,  sometimes  even  all  day,  so  that  the  patient 
is  obliged  to  lie  down,  and  is  utterly  incapable  of 
attending  to  any  business.  In  some  instances  the  pain 
does  not  set  in  until  a quarter  or  half  an  hour  after  the 
bowels  have  acted. 

In  children  and  young  persons,  unless  a polypus 
complicates  the  fissure,  I think  it  is  almost  always 
curable  without  operation.  I have  had  many  cases 
resembling  the  following. 

A child,  set.  4f,  admitted  into  St  Mark’s,  September,  1867.  For 
twelve  months  or  more  he  has  been  subject  to  procidentia  every  time 
his  bowels  acted  ; he  is  usually  rather  constipated.  About  five  or  six 
months  ago  he  began  to  suffer  pain,  which  lasted  for  hours  after  the 
bowels  had  been  relieved ; this  was  so  severe  that  he  screamed  and 
rolled  about  in  his  bed ; he  often  passed  a little  blood ; the  pain  was 
much  aggravated  when  he  was  costive.  On  an  injection  being  given, 
the  rectum  came  down,  and  a very  distinct  fissure  with  a papillary 


FISSURE  OF  THE  ANUS 


193 


growth  at  its  commencement  was  seen.  There  was  no  polypus  in  the 
bowel ; Ung.  Zinci  with  extract  of  belladonna  and  opium  was  ordered 
to  be  used  night  and  morning,  and  confection  of  senna  with  sulphur 
to  be  taken  to  keep  the  bowels  gently  acting.  This  prescription  afforded 
immediate  relief ; in  three  weeks  the  ulcer  was  healed  and  the  child 
perfectly  cured. 

In  children  suffering  from  hereditary  syphilis, 
numerous  small  cracks  round  the  anus  are  common, 
and  they  cause  much  pain.  Mercurial  applications 
and  extreme  cleanliness  soon  cure  them,  but  they  will 
return  from  time  to  time  unless  anti-syphilitic  medi- 
cines be  taken  for  a lengthened  period. 

Fissure,  although  really  so  simple  a matter,  and  its 
cure  generally  so  easy,  wears  out  the  patient’s  health 
and  strength  in  a remarkable  manner;  the  constant 
pain  and  irritation  to  the  nervous  system  are  more 
than  most  persons  can  bear;  I have  frequently  seen 
women  suffering  from  small  anal  ulcer,  who  thought 
they  must  have  cancer  in  consequence  of  their  extreme 
illness  and  pain.  What  under  these  circumstances  is 
very  extraordinary  is  the  length  of  time  people  go  on 
enduring  the  malady  without  having  anything  done 
for  it.  It  is  not  an  uncommon  thing  for  one  to  see 
fissures  of  many  years’  duration,  especially  in  young 
women,  who,  through  delicacy  of  feeling,  often  conceal 
rectal  affections. 

It  is  common  for  fissures  to  heal  for  a time  and 
then  break  out  again,  so  patients  are  apt  to  think  a 
perfect  cure  will  presently  result,  and  defer  proper 
treatment. 

The  usual  position  on  the  side  is  the  best  for 
making  an  examination.  Let  the  patient  raise  the 
upper  buttock  with  the  hand,  then  with  your  fore- 
finger and  thumb  gently  open  the  anus,  at  the  same 

13 


194 


FISSURE  OF  THE  ANUS 


moment  telling  the  patient  to  strain  down ; yon  will 
then  be  able  to  see  just  within  the  orifice  an  elon- 
gated, club-shaped  ulcer ; the  floor  of  it  may  be  very 
red  and  inflamed,  or,  if  the  ulcer  is  of  long  standing, 
of  a greyish  colour  with  the  edges  well-defined  and 
hard. 

Frequently  the  site  of  the  fissure  is  marked  exter- 
nally by  a small  clavate  papilla  or  minute  muco- 
cutaneous polypoid  growth;  this  must  not  be  con- 
founded with  ordinary  polypus,  and  it  is  not  the  cause 
of  the  fissure,  but  the  result  of  the  local  irritation  and 
inflammation  which  have  been  going  on.  Sometimes 
the  situation  of  the  fissure  is  indicated  by  an  inflamed 
and  swollen  piece  of  skin,  and  in  this  case  ulceration 
through  the  portion  of  the  integument  not  infrequently 
occurs,  and  a small  but  extremely  painful  fistula 
results.  In  such  a case  very  probably  a small  abscess 
had  formed  just  above  the  external  sphincter,  and  had 
burrowed  under  it,  making  in  time  a complete  fistula. 
These  small  abscesses  are  very  painful.  It  occurred 
to  me  to  observe  this  in  the  wife  of  a medical  man. 
When  I first  examined  her  I found  she  had  well- 
marked  fissure  and  an  inflamed  piece  of  skin  close  to 
the  anus.  I predicted  that  the  ulceration  would  per- 
forate this,  and  so  it  did,  for  in  about  ten  days  when 
I went  to  operate  upon  her,  I found  a small  fistula 
had  formed. 

Occasionally,  on  proceeding  to  examine  a patient, 
the  first  thing  you  see  is  the  small  club-shaped  papilla 
I have  already  mentioned  protruding  from  the  anus ; 
you  may  then  be  certain  that  an  ulcer  exists.  I may 
here  mention  that  when  operating,  this  growth  ought 
to  be  snipped  off,  or  the  case  may  not  do  well,  as  it 


FISSURE  OF  THE  ANUS 


195 


falls  down  into  the  wound  and  retards  or  quite  pre- 
vents healing. 

Fissure  is  very  commonly  associated  with  uterine 
displacement.  I have  stated  that  operations  upon 
haemorrhoids  under  similar  conditions  are  not  satis- 
factory ; the  same  observation  applies  with  quite  as 
much  truth  to  fissure  and  uterine  disease.  I have 
many  times  had  reason  to  repent  interfering  with 
these  cases.  The  successful  treatment  of  the  uterine 
disorder  may  be  sufficient  to  cure  the  fissure  (if  no 
polypus  exists),  or  at  all  events  the  ulcer  will  after- 
wards yield  to  local  applications  and  general  treat- 
ment. If  the  fissure  should  be  benefited  by  operation, 
as  long  as  the  uterine  malady  exists  there  will  be  a 
constant  danger  of  a relapse  taking  place.  The  most 
common  forms  of  uterine  displacement  in  connection 
with  fissure  are,  according  to  my  experience,  antever- 
sion  and  retroversion,  and  associated  with  these  I have 
frequently  observed  affections  of  the  bladder,  chronic 
cystitis,  and  spasmodic  pains  in  micturition.  When 
you  find  these  three  disorders  united,  depend  upon  it 
you  will  have  a case  that  will  call  for  all  your  skill  and 
patience  to  bring  to  a successful  issue. 

Gelatinous  and  fibrous  polypi  are  not  at  all  uncom- 
mon complications  of  fissure.  The  polypus  is  usually 
situated  at  the  upper  or  internal  end  of  the  fissure, 
but  it  may  be  on  the  opposite  side  of  the  rectum. 
Here  is  a case  : 


Mary  G — , set.  47,  was  admitted  into  St  Mark’s,  April,  1871.  She  had 
a well-marked  and  very  painful  fissure  near  the  anus.  There  was  no 
polypus  to  be  seen,  but  on  passing  my  finger  into  the  rectum  I found  a 
pedunculated  fleshy  polypus  on  the  opposite  side  of  the  bowel  to  that 
on  which  the  fissure  was  situated.  I am  quite  confident  that  had  I 


196 


FISSURE  OF  THE  ANUS 


incised  tlie  fissure  and  left  the  polypus  this  patient  would  not  have 
recovered. 

If  you  do  not  remove  a polypus  at  the  time  you 
divide  the  ulcer,  failure  is  certain  to  result,  as  I have 
myself  seen  many  times. 

If  the  fissure  is  of  recent  origin  it  may  often  be 
cured  without  operation,  especially  if  it  be  situated 
anteriorly.  In  women  this  can  almost  certainly  be 
accomplished.  Of  all  the  varieties  of  fissure  the  syphi- 
litic is  most  amenable  to  general  treatment ; when  of 
syphilitic  origin  they  are  often  multiple.  I have  noticed 
three  distinct  well-marked  fissures  in  one  patient.  I 
have  seen  in  the  practice  of  my  colleagues  at  St  Mark’s 
many  instances  of  multiple  fissure.  I may  here  mention 
that  if  you  are  obliged  to  operate  upon  a multiple 
fissure  one  incision  through  the  sphincter  will  be 
sufficient. 

Now  as  to  the  treatment.  In  all  cases,  rest  in  the 
recumbent  position  should,  as  much  as  possible,  be 
adopted.  Mild  laxatives  should  be  given,  not  to  purge 
but  to  keep  the  bowels  acting  once  daily ; this  may 
sometimes  be  effected  by  diet  alone.  The  domestic 
remedy  of  figs  soaked  in  sweet  oil,  or  onions  and  milk 
at  bedtime,  may  be  sufficient.  I often  order  a com- 
bination of  equal  parts  of  the  confection  of  sulphur 
and  confection  of  senna;  small  doses  of  sulphate  of 
magnesia  or  sulphate  of  potash,  half  a tumbler  of  Pullna 
or  Friedrich  shall  water  taken  in  the  morning  fasting, 
the  compound  liquorice  powder  of  the  German  phar- 
macopoeia, and  the  liquid  extract  of  the  Rhamnus 
frangula  are  great  favourites  of  mine. 

You  must  be  prepared  to  alternate  the  medicines  as 
one  or  other  seems  to  lose  its  effect.  All  drastic  purges 


FISSURE  OF  THE  ANUS 


197 


should  be  avoided,  but  I do  not  object  to  small  doses 
of  the  aqueous  extract  of  aloes,  especially  when  com- 
bined with  nux  vomica  and  iron.  It  will  be  an  advan- 
tage if  the  patient  can  manage  to  get  the  bowels  to  act 
the  last  thing  at  night  instead  of  in  the  morning,  as  the 
rest  is  very  beneficial  and  the  pain  does  not  continue  so 
long  when  lying  down.  After  the  action  3SS  of  Liq.  Opii 
sedativus  may  be  injected  with  3ij  of  cold  starch ; this 
is  especially  valuable  if  the  patient  has  the  bowels 
relieved  at  bedtime.  As  an  application  I know  nothing 
better  than  the  following  ointment : Hydrarg.  Sub- 
chloridi  gr.  iv,  Pulv.  Opii  gr.  ij,  Ext.  Belladonna  gr.  ij, 
Unguent.  Sambuci  3j,  to  be  applied  frequently.  I 
have  effected  many  cures  with  this  ointment  alone.  An 
occasional  very  light  touch  with  the  nitrate  of  silver 
(not  to  cauterise  but  to  sheathe  the  part  with  an 
albuminate  of  silver)  is  useful,  and  it  relieves  pain  for 
some  time.  If  there  be  very  great  spasm  of  the 
sphincter,  extract  of  belladonna  maybe  thickly  smeared 
around  the  anus  over  the  muscle,  and  this  I have  at 
times  found  effective.  If  ointments  do  not  agree  with 
the  sore  lotions  may  be  preferable ; Goulard  water  with 
opiates  and  sedatives  may  afford  some  temporary  relief, 
but  one  must  acknowledge  that  the  best  devised  and 
most  carefully  carried  out  general  treatment  frequently 
fails,  save  in  favorable  cases. 

In  my  opinion,  if  the  base  of  the  ulcer  be  grey  and 
hard,  and  if  on  passing  the  finger  into  the  bowel  you 
find  the  sphincter  hypertrophic  and  spasmodically 
contracted,  feeling  as  it  often  does  like  a strong  india- 
rubber  band  with  its  upper  edge  sharply  and  hardly 
defined,  nothing  but  the  adoption  of  such  means 
as  will  utterly  and  entirely  prevent  all  action  of  the 


198 


FISSURE  OF  THE  ANUS 


muscle,  for  a greater  or  less  length  of  time,  is  likely  to 
effect  a cure  of  the  fissure. 

Some  authors  specify  the  time  at  which  this  disease 
may  be  curable  without  operation,  and  say,  “If  it  has 
existed  more  than  three  months  the  attempt  is  hope- 
less,” but  really  the  time  is  not  of  importance ; the 
question  is,  what  pathological  changes  have  been 
brought  about?  I have  cured  fissure  of  months’ 
standing  when  there  was  no  great  hypertrophy  of  the 
muscles.  Here  are  some  cases. 

Mrs  E — , set.  24,  was  sent  to  me  by  Dr  Simpson,  of  the  Old  Kent 
Road.  Five  months  ago  she  was  confined  with  her  first  child  after  a 
somewhat  lingering  labour.  The  first  time  the  bowels  acted  she  had 
pain  ; and  ever  since  then  she  has  never  had  an  action  without  suffer- 
ing. This  has  been  gradually  increasing  and  now  her  life  is  almost 
unendurable;  the  pain  lasting  for  hours,  and  compelling  her  to  lie 
down,  so  that  she  is  quite  unable  to  attend  to  her  household  duties. 
On  examination  a very  characteristic  dorsal  fissure  was  seen ; there 
was  no  polypus  or  piles.  The  rectum  was  generally  healthy,  and  there 
was  not  very  marked  spasm  or  thickening  of  the  sphincter.  The  bowels 
were  confined.  Ordered  Magnes.  Sulph.  5j\  Ferri  Sulph.  gr.  j,  Acid 
Sulph.  dilut.  Tfiv,  Inf.  Quassise  %j,  ter  die ; and  to  use  the  following 
ointment — Ung.  Hydrarg.  subchlor.  5j>  Ext.  Opii,  Ext.  Belladonnse, 
aa  gr.  iij ; to  be  applied  after  action  of  the  bowels  and  also  at  night. 
I touched  the  ulcer  every  other  day  with  a solution  of  perchloride  of 
mercury.  In  a fortnight  the  fissure  was  nearly  healed,  and  she  had 
scarcely  any  pain  after  defsecation.  Soon  after  this  I heard  she  had 
got  quite  well. 

A city  dignitary  consulted  me  some  time  back,  on  the  recommenda- 
tion of  Dr  Sedgwick  Saunders.  His  history  was  that  for  eighteen 
months  or  more  he  had  suffered  pain  on  defsecation;  at  times  he  was 
much  better  and  only  experienced  uneasiness,  and  then  again  the  pain 
returned  as  bad  as  ever.  Homoeopathy  had  been  tried  for  some  six  or 
seven  months,  and  he  had  derived  benefit  as  far  as  his  constipation  was 
concerned,  but  the  pain  was  no  better.  He  had  cultivated  the  habit  of 
getting  his  bowels  to  act  about  six  o’clock  in  the  morning,  so  that 
afterwards  he  could  return  to  bed  and  lie  quiet  for  a couple  of  hours  ; 
he  was  then  able  to  get  up  and  come  to  town  by  train  without  suffering 
much ; but  if  he  had  to  travel  soon  after  visiting  the  water-closet  he 


FISSURE  OF  THE  ANUS 


199 


was  in  pain  all  day.  He  was  very  careful  in  his  diet,  drank  very  little 
wine,  and  was  accustomed  to  take  oatmeal  porridge,  brown  bread, 
fruits,  and  vegetables,  which  I dare  say  had  more  effect  on  his  bowels 
than  the  globules  of  nux  vomica  to  which  he  attributed  his  regularity. 
As  he  laid  very  much  stress  upon  the  use  of  these  globules,  and  was 
strongly  of  opinion  that  he  would  have  no  action  without  them,  I did 
not  oppose  their  continuance,  knowing,  as  I well  do,  how  much  the 
belief  that  a certain  drug  is  beneficial  tends  to  make  it  so.  On  examin- 
ing this  patient  I found  a small  circular  perineal  ulcer  situated  at  the 
upper  edge  of  the  external  sphincter ; it  was  clean  cut  and  inflamed. 
The  rectum  was  otherwise  healthy,  and  the  sphincter  was  not  much 
hypertrophied.  Taking  into  consideration  the  length  of  time  the  ulcer 
had  existed  I advised  incision,  but  that  he  would  not  listen  to,  so  I pre- 
scribed my  usual  ointment,  but  was  speedily  obliged  to  leave  out  the 
extract  of  belladonna,  as  he  was  so  sensitive  to  the  action  of  this  drug 
as  to  get  dry  mouth  and  dilated  pupils  with  affected  vision  in  twenty  - 
four  hours  after  applying  it.  After  three  weeks  I found  the  ulcer  was 
not  any  better,  although  I had  varied  my  treatment,  touched  it  with 
nitrate  of  silver,  perchloride  of  mercury,  &c. ; he  had  also  used  lotions 
of  the  tartrate  and  persulphate  of  iron.  I had  observed  that  there  was 
one  minute  spot  most  excessively  tender,  much  more  so  than  the  rest  of 
the  sore.  There,  no  doubt,  was  an  exposed  nerve,  so  I took  a hint  from 
the  late  Mr  Hilton’s  work  on  ‘ Rest  and  Pain,’  and  applied  once,  some 
acid  nitrate  of  mercury.  From  that  day  the  ulcer  rapidly  healed  and 
soon  this  gentleman  got  perfectly  well ; I know  that  he  continues  so  to 
this  day. 

I may  here  remark  that  I have  several  times  had  a 
similar  success  from  the  fuming  nitric  acid,  but  I prefer 
the  acid  nitrate  of  mercury.  I have  had  very  good 
results  from  a suppository  of  oxide  of  mercury. 

A lad,  set.  19,  came  to  me  at  St  Mark’s  with  double  fissure : both  the 
ulcers  were  very  well  marked,  and  there  was  one  on  either  side  of  the 
anus.  He  suffered  the  greatest  pain  for  hours  after  defsecation.  On 
examining  him  I found  that  he  had  a syphilitic  rash — squamous  and 
coppery ; his  tonsils  were  ulcerated,  and  he  had  also  enlarged  and  har- 
dened glands  in  his  groin.  He  admitted  that  he  had  suffered  from  a 
sore  on  his  penis,  and  had  been  treated  for  it  at  St  Bartholomew’s 
Hospital ; he  did  not  know  whether  he  had  taken  mercury  or  not.  The 
sore  on  the  penis  had  been  well  about  five  months,  and  the  pain  on 
going  to  stool  had  existed  for  four  months.  The  rectum  was  healthy, 
and  there  were  no  mucous  tubercles.  I put  him  on  a course  of  bichloride 


200 


FISSURE  OF  THE  ANUS 


of  mercury  and  tonics  as  lie  was  mucli  out  of  health ; he  took  the  hos- 
pital confection  to  keep  his  bowels  gently  acting,  and  used  strong 
calomel  ointment  with  powdered  opium ; after  three  weeks’  treatment 
the  fissures  had  quite  healed,  so  then  he  ceased  to  attend,  although  his 
syphilitic  symptoms  had  not  disappeared. 

I have  headed  this  chapter  “ Fissure  and  painful 
irritable  ulcer”  because  the  symptoms  and  treatment 
do  not  differ  whatever  form  the  ulcer  assumes,  whether 
it  be  elongated  and  club-shaped,  oval,  or  circular,  but 
as  a rule  the  small  circular  ulcer  is  situated  higher  up 
the  bowel  than  fissures  are,  which  generally  extend  to 
the  junction  of  the  mucous  membrane  with  the  skin  ; 
the  ulcer  being  more  commonly  found  above  or  about 
the  lower  edge  of  the  internal  sphincter  ani.  I think 
also  that  in  the  circular  ulcer  there  is  less  severe  pain 
at  the  moment  of  defecation,  but  it  comes  on  from  five 
minutes  to  a quarter  or  half  an  hour  after  that  act, 
and  then  is  quite  as  intolerable  as  that  resulting  from 
the  fissure.  These  minute  ulcers  are  more  difficult  to 
find  than  the  fissures,  as  they  often  cannot  be  seen 
without  the  use  of  a speculum,  or  getting  the  patients 
to  strain  violently,  which  they  will  not  do  for  fear  of 
exciting  pain ; in  fact,  they  generally  draw  up  the 
anus  as  much  as  they  can  when  you  are  examining 
them.  An  educated  finger  detects  these  ulcers  directly ; 
they  feel  much  like  the  internal  aperture  of  a fistula, 
but  the  edges  are  harder,  and  therefore  more  defined ; 
and  there  is  no  elevation  above  the  surface  of  the  sur- 
rounding mucous  membrane,  as  is  frequently  the  case 
in  fistula.  These  ulcers  often  burrow,  and  then  they 
become  the  internal  openings  of  blind  internal  fistulas. 

There  has  been  a controversy  at  various  times  as  to 
the  depth  of  incision  necessary  to  cure  a fissure,  some 


FISSURE  OF  THE  ANIJS 


201 


advocating  a slight  cut  and  others  a free  one.  There  is 
no  doubt  that  in  some  cases  a very  superficial  incision 
through  the  base  of  the  fissure,  so  as  to  divide  the 
fibres  of  the  muscles  immediately  beneath  the  ulcer,  or 
even  to  cut  through  an  inflamed  filament  of  nerve , may 
be  enough  ; but,  on  the  other  hand,  I have  frequently 
seen  slight  incisions  fail,  and  I am  confident  that  a 
tolerably  free  one,  sufficient  to  secure  the  relaxation  of 
the  sphincter,  and  put  the  parts  entirely  at  rest,  is  by 
far  the  safer  plan ; and  this,  indeed,  is  the  physio- 
logical reason  of  the  success  attending  the  operation. 

I do  not  mean  by  this  that  you  need  cut  right 
through  both  sphincters  into  the  cellular  space  be- 
neath, as  the  older  surgeons  used  to  do,  but  I am  sure 
that  a fairly  free  incision  heals  quite  as  quickly  as  a 
small  one,  and  that  it  is  much  better  to  cut  rather  too 
deeply  than  too  superficially. 

Those  who  are  in  favour  of  a slight  cut  say  that 
incontinence  of  fasces  may  be  brought  about  by  too 
free  an  incision  through  the  muscles.  That  may  be 
the  case  when  the  cut  is  not  properly  made,  i.  e.  when 
the  muscles  are  not  cut  at  right  angles  to  the  direc- 
tion of  their  fibres.  An  incision  at  right  angles  will 
join  so  as  to  leave  a perfect  narrow  scar,  but  an 
oblique  incision  leaves  a very  weak,  wide  scar.  I am 
quite  certain  that  both  the  internal  and  external 
sphincter  muscles  (on  one  side  only)  may  be  divided 
entirely  in  a healthy  person,  without  any  danger  of  a 
weak  bowel  following. 

You  may  be  confident  that  your  patient  will  not 
readily  pardon  your  not  curing  him  at  the  first  opera- 
tion, and  will  be  very  disinclined  to  submit  to  a second 
incision  should  the  first  have  failed.  Most  likely  he 


202 


FISSURE  OF  THE  ANUS 


will  take  himself  out  of  your  hands,  and  seek  other 
advice ; it  has  occurred  to  me  to  have  to  operate  upon 
patients,  both  hospital  and  private,  where  eminent 
surgeons  had  failed  to  effect  a cure,  and  I have  found 
that  failure  had  resulted  from  one  of  two  causes,  either 
the  too  sparing  use  of  the  knife,  or  the  overlooking  of 
a polypus. 

When  operating,  if  not  very  an  fait  at  rectal  surgery, 
I should  advise  you  to  introduce  a speculum ; you 
then  see  exactly  where  your  knife  should  go,  and  the 
parts  are  also  rendered  tense,  so  that  their  division  is 
facilitated ; the  incision  should  commence  a little  above 
the  upper  end  of  the  fissure,  and  terminate  a little 
beyond  the  outer  end,  so  that  the  whole  sore  is  cut 
through  ; as  a general  rule  the  depth  of  incision  should 
not  be  less  than  a quarter  of  an  inch.  If  the  outer 
end  of  the  fissure  be  marked  by  a swollen  inflamed 
piece  of  skin,  it  is  better  to  remove  that  with  a pair  of 
scissors,  for  by  so  doing  the  healing  process  is  greatly 
expedited;  the  small  polypoid  growth  also,  so  fre- 
quently found  in  fissure,  should  at  the  same  time  be 
snipped  off.  Please  to  note  that  I am  not  recommend- 
ing the  cutting  off  of  true  rectal  polypi . 

It  has  been  suggested  that  a curved  bistoury  may  be 
passed  beneath  the  ulcer,  and  the  cut  made  from  beneath 
towards  the  bowel.  I do  not  see  any  advantage  in 
this  mode  of  operating;  for  my  own  part,  I always 
insert  my  forefinger  into  the  bowel,  feel  the  situation 
of  the  fissure,  pass  upon  my  finger  a straight  knife 
with  a rounded  point,  then  turn  the  edge  to  the  base 
of  the  ulcer  and  make  the  incision ; or,  the  knife-blade 
can  be  laid  flat  upon  the  forefinger  and  both  intro- 
duced together  into  the  bowel,  and  the  cut  then  made ; 


FISSURE  OF  THE  ANUS 


203 


this  is  a good  plan  where  there  is  much  spasm  of  the 
sphincter.  When  the  fissure  is  quite  dorsal,  the  cut 
should  be  made  not  directly  through  it,  but  somewhat 
laterally,  by  which  means  you  are  certain  of  completely 
dividing  the  fibres  of  the  muscle,  and  the  wound  will 
heal  more  readily.  A small  piece  of  cotton  wool  may 
be  placed  in  the  wound,  and  allowed  to  remain  for 
twenty-four  or  forty-eight  hours.  It  is  well  to  keep 
the  bowels  confined  for  two  or  three  days. 

Usually  there  is  no  occasion  for  the  patient  to  keep 
in  bed,  but  it  is  advisable  that  much  exercise  or  stand- 
ing about  should  be  interdicted ; a few  days’  rest  on 
the  sofa  is,  in  simple  cases,  all  that  is  required.  The 
reverse  of  all  this  is  absolutely  necessary  when  there  is 
any  uterine  complication ; the  patient  here  must  be 
kept  entirely  at  rest  and  lying  down  until  the  wound 
has  soundly  healed,  for,  most  assuredly,  if  she  gets 
about  too  soon  either  the  wound  will  not  close,  or  a 
worse  result,  viz.  unhealthy  ulceration,  will  ensue. 
I have  seen  many  cases  showing  the  good  policy  of 
long-continued  rest,  and  numbers  more  where  bad 
results  have  followed  a speedy  resumption  of  ordinary 
duties  ; on  this  point  I could  relate  numerous  illustra- 
tive cases,  but  one  shall  suffice. 

Ada  T — was  admitted  into  St  Mart’s  Hospital  August,  1866 ; she 
was  twenty-four  years  of  age,  was  married,  and  had  five  children ; she 
was  in  the  hospital  three  months  ago,  and  was  operated  upon  by  Mr 
Lane  for  fissure ; she  left  not  quite  well.  It  was  noted  on  her  card 
that  she  suffered  from  retroversion,  and  had  an  enlarged  uterus.  On 
examining  her,  on  her  re-admission,  rather  extensive,  but  superficial 
ulceration  was  found  to  have  taken  place  since  her  going  out.  The 
ulceration  extended  above  the  upper  edge  of  the  internal  sphincter. 
She  had  a good  deal  of  pain  and  frequent  harassing  diarrhoea.  There 
was  no  history  or  sign  of  syphilis.  After  three  months’  treatment  by 
injections,  sedative  and  astringent,  and  the  internal  administration  of 


204 


FISSURE  OF  THE  ANUS 


iodide  of  potassium  and  tonics,  she  was  discharged  cured.  The  uterus 
was  kept  in  its  place  by  means  of  a Hodge’s  pessary. 

These  fissures,  or  irritable  ulcers,  not  very  uncom- 
monly give  rise  to  a train  of  nervous  and  hypochon- 
driacal sensations,  which  continue  even  after  the  ulcer 
itself  has  healed.  I have  seen  examples  of  this  in 
both  hospital  and  private  practice,  and  both  in  men 
and  women. 

An  elderly  maiden  lady  has  been  seen  by  me  at  various  times  for  the 
last  four  or  five  years,  her  history  being  that,  fully  five  years  back,  she  had 
a small  painful  ulcer  situated  over  the  upper  part  of  the  internal  sphincter 
muscle,  which  was  much  hypertrophied  and  spasmodically  contracted. 
A limited  division  of  the  muscle  failed  to  effect  a cure,  and  after  six 
months’  trial  to  get  the  ulcer  to  heal  I again  operated,  this  time  assisted 
by  my  friend  Dr  Crosby ; I made  a very  free  incision  through  both 
muscles,  and  after  that  there  was  no  difficulty,  the  wound  healed  tho- 
roughly and  soundly ; but  ever  since  then,  although  there  is  not  the 
slightest  lesion  of  the  bowel — I have  often  examined  her  with  both  spe- 
culum and  endoscope  in  the  most  thorough  manner  to  be  sure  of  that 
fact ; she  frequently,  indeed  almost  constantly,  complains  of  her  old 
pain.  There  is  a burning,  uneasy  sensation  in  the  bowel,  but  no  local 
tenderness  to  touch.  She  cannot  walk  about  much,  nor  sit  long  in  one 
position,  nor  ride  far  in  any  vehicle  without  suffering.  She  is  stout, 
looks  well,  and  her  general  health  has  not  suffered.  There  is  no  dis- 
charge of  any  kind,  mucous,  purulent,  or  bloody ; and,  as  a rule,  she 
does  not  have  pain  on  defaecation.  There  is  no  abnormal  redness  or 
heat  of  the  bowel,  although  she  always  has  the  sensation  of  great  heat 
in  the  part.  She  has  no  uterine  affection  (two  eminent  obstetric 
physicians  have  examined  her  and  say  so),  and  she  has  ceased  men- 
struating some  years. 

Now,  wbat  is  tbe  matter  with  this  patient  ? Some 
may  call  it  neuralgia  or  hysteria ; but  it  has  resisted 
all  the  usual  remedies  prescribed  for  these  complaints, 
including  hypodermic  injections  of  morphia  and 
quinine ; in  fact,  she  has  taken  all  kinds  of  remedies 
prescribed  by  other  medical  men  as  well  as  myself.  I 
have  two  ideas  as  to  the  cause  of  suffering  in  this 


FISSURE  OF  THE  ANUS 


205 


case  : — The  first  is,  that  it  is  possible  that  some  fila- 
ment of  nerve  is  included  in  the  cicatrix  of  the  wound, 
and  thus  irritation  or  inflammation  is  kept  up,  as  one 
sees  occasionally  after  amputations  of  the  extremities  ; 
the  second  idea  is,  that  her  mind  has  been  dwelling  for 
so  long  a time  on  the  state  of  her  bowel  that,  although 
now  there  is  nothing  organically  the  matter  with  her, 
she  retains  the  power,  by  mental  concentration,  of 
reproducing  the  sensation  of  pain  in  the  old  spot. 
This  may  not  be  the  correct  explanation,  but  there  is 
some  evidence,  I think,  tending  to  show  that  it  possibly 
is  so ; for  instance,  the  pain  is  not  always  consistent 
in  its  behaviour ; the  bowels  act  generally  without  pain  ; 
the  pain  does  not  come  on  directly  after  defsecation, 
but  some  hours  after  ; sometimes  the  pain  sets  in  before 
the  action,  and  is  removed  or  relieved  by  the  bowel 
being  emptied  (a  condition  of  things  quite  inconsistent 
with  the  presence  of  true  ulcer  or  fissure) . Then,  again , 
when  the  patient  is  occupied  pleasantly  or  intently  she 
has  no  pain,  but  it  can  be  produced  immediately  by 
excitement  of  a disagreeable  kind  ; it  is  also  uncertain 
in  its  coming  and  going,  as  well  as  in  its  character ; 
sometimes  it  is  smarting,  then  burning,  as  if  the  rectum 
were  very  hot ; at  another  time  pulsation  is  the  chief 
annoyance,  or  the  bowel  may  feel  quite  plugged  up  as 
if  the  anus  were  swollen ; and  then  suddenly  the  pain 
is  lancinating,  causing  her  to  call  out : all  this  leads  me 
to  think  that  the  pain  is  mental. 

Whatever  may  be  the  explanation,  the  fact  is  clear 
that  here  is  a person  who  has  no  discoverable  lesion  of 
structure  in  a part,  constantly  suffering  almost  all  the 
pain  and  misery  which  was  formerly  induced  by  a 
marked  organic  disease.  This  patient  has  written  to 


206 


FISSURE  OF  THE  ANUS 


me  stating  that  she  is  now  quite  well,  although  nothing 
special  has  been  done  for  her.  I have  not  related  this 
case  because  it  is  unique ; I have  seen  others  precisely 
similar  both  in  men  and  women.  I know  for  years  T 
was  tormented  at  the  hospital  by  a man,  perfectly 
healthy  and  strong  looking,  who  used  constantly  to 
attend  the  out-patient  room  complaining  of  a dreadful 
burning  and  painful  sensation  in  the  rectum  a little  way 
from  the  anus ; he  said  it  kept  him  awake  at  night, 
haunted  him  all  day,  was  never  out  of  his  thoughts, 
and  made  his  life  utterly  miserable.  I examined  him 
many  times  and  could  never  detect  anything  abnormal 
(he  had  been  operated  upon  for  fissure  years  before  I 
saw  him  by  the  late  Mr  Salmon) ; there  was  no  red- 
ness, no  discharge,  and  the  thermometer  showed  no 
excessive  heat ; in  fact  there  was  nothing  to  see  or  feel. 
No  remedy  did  him  any  permanent  good,  but  he  was 
always  a little  benefited  by  a fresh  one.  He  used  to 
leave  me  every  now  and  again  and  go  to  one  of  my 
colleagues,  and  glad  I was  to  be  quit  of  him,  but  in  a 
few  months  he  was  sure  to  come  back,  and  not  a whit 
better  for  what  had  been  done  for  him.  I called  the 
malady  hypochondriasis,  but  I suppose  that  was  only 
expressing  by  a long  word  that  I did  not  understand 
what  was  the  matter  with  him.  I can  emphatically  say 
that  such  patients  are  about  the  most  unsatisfactory 
you  can  have. 

Why  are  ulcers  near  the  anus  so  very  painful,  while 
those  situated  higher  up  the  bowel  are  not  generally 
so  ? There  are  two  reasons  which  suggest  themselves  at 
once  : — 1st,  the  great  mobility  of  the  external  sphincter; 
2nd,  the  supply  of  nerves.  The  lower  part  of  the 
rectum  and  the  anus  are  very  fully  supplied  by  branches 


FISSURE  OF  THE  ANUS 


207 


from  the  posterior  and  anterior  sacral  plexus,  and  more 
especially  from  the  pudic.  These  nerves  send  numerous 
branches  between  the  fibres  of  the  sphincters  and  im- 
mediately beneath  the  mucous  membrane ; thus  very 
superficial  ulceration  exposes  the  nerve,  and  the 
slightest  touch,  contraction,  or  stretching  of  the 
sphincter  causes  intense  pain. 

If  you  carefully  examine  one  of  these  ulcers  you 
will  usually  find  one  or  more  spots  that  are  most  ex- 
quisitely tender ; this  is  where  the  nerve  is  exposed. 
The  lightest  drawing  of  the  knife  across  the  ulcer,  if 
done  at  the  right  point,  will  be  sufficient  to  divide  this 
nerve,  and  to  induce  cessation  of  the  pain  for  some  little 
time ; but  the  muscle  beneath  being  irritated  and 
hypertrophied  prevents  by  its  movements  the  ulcer 
from  healing,  and  very  soon  the  pain  will  be  re- 
established ; hence  the  necessity  in  all  but  the  slightest 
cases  for  the  division  of  the  sphincter. 

When  the  muscle  is  cut  the  divided  fibres  retract, 
and  they  do  not  unite  so  quickly  as  the  ulcer  heals ; the 
result  is  that  the  muscle,  being  set  quite  at  rest,  soon 
loses  its  hypertrophy  and  irritability.  I have  often 
noticed,  after  a fissure  has  been  cured,  how  much  re- 
duced in  size  and  thickness  both  the  sphincters  have 
become.  The  cause  of  failure  after  imperfect  division 
of  the  muscle  is,  that  entire  quiet  is  not  obtained; 
the  undivided  fibres,  though  paralysed  for  a time,  soon 
recover  themselves,  and  the  old  contraction  is  resumed 
before  the  ulcer  has  had  time  to  heal,  so  that  very 
speedily  it  re-assumes  its  former  character. 

A great  many  apparently  anomalous  symptoms  are 
produced  by  small  painful  ulcers  of  the  rectum — reten- 
tion of  urine,  pain  in  the  back,  pain  and  numbness  down 


208 


FISSURE  OF  THE  ANUS 


the  back  of  the  legs,  leading  to  unfounded  fears  of  para- 
lysis, may  be  mentioned  as  not  uncommon.  When  in 
a fissure  the  nerves  are  exposed  the  pain  is  most  acute 
at  the  time  of  an  evacuation ; when  they  are  not  so 
exposed  the  pain  generally  sets  in  shortly  after  the 
action  in  consequence  of  the  irritation  to  the  sphincter. 
In  many  of  these  ulcers  an  examination  with  a magni- 
fying  glass  has  shown  me  the  fibres  of  the  external 
sphincter  laid  quite  bare.  Patients  sometimes  tell 
you  that  the  first  time  they  suffered  pain  was  after 
a very  hard  motion,  when  they  felt  something  give  way 
with  a crack. 

Dr  Dolbeau,  of  Paris,  considers  the  essence  of  this 
disorder  to  be  neuralgic,  and  defines  “ fissure  of  the 
anus  as  being  a spasmodic  neuralgia  of  the  anus  with 
or  without  fissure.5 5 He  states  that  he  has  seen  cases 
where  all  the  intense  pain  and  agony  of  fissure  were 
present,  but  no  structural  lesion  whatever  could  be 
detected.  For  my  own  part  I cannot  wholly  subscribe 
to  this  view  ; out  of  the  thousands  of  patients  who  have 
been  under  my  care  suffering  from  rectal  diseases,  I 
have  never  yet  met  with  a case  in  which  the  persis- 
tent, regularly  repeated,  intense  pain,  commencing  on 
passing  or  immediately  after  the  passing  a motion, 
which  distinguishes  fissure,  was  not  associated  with  an 
anatomical  lesion,  though  that  lesion  might  be  very 
slight  and  difficult  to  discover. 

I have  seen  a good  many  nervous  patients  who  com- 
plained of  rectal  or  anal  pains  severe  in  character,  but 
still  wanting  the  essential  characteristics  of  the  pain  of 
fissure.  I have  also  observed  cases  of  spasmodic  con- 
traction of  the  sphincter  inducing  obstinate  constipa- 
tion and  attended  with  pain,  but  not  at  all  strongly 


FISSURE  OF  THE  ANUS 


209 


resembling  the  paroxysm  due  to  fissure ; often  a sudden 
spasmodic  acute  stab  seems  to  run  up  tbe  bowel  just 
before  action,  but  when  the  fascal  mass  is  passed  a 
feeling  of  relief  and  comfort  is  experienced.  I do  not 
say  that  neuralgia  may  not  coexist  with  fissure,  and 
modify  or  aggravate  the  suffering,  but  I think  if  it 
were  the  essential  cause  of  the  pain  I should  be  jus- 
tified in  expecting  that  this  would  occasionally  yield  to 
the  internal  exhibition  of  anti-neuralgic  remedies,  a 
result  which  certainly  is  not  within  the  range  of  my 
knowledge.  I am  inclined,  but  doubtingly,  to  express 
the  opinion  that  the  one  essential  of  the  malady  in  its 
severest  form  is  an  exposed  nerve,  and  that  the  spas- 
modic contraction  of  the  sphincter,  excited  by  reflex 
irritation,  occasions  the  peculiar  character  of  the 
pain. 

Dr  Dolbeau  is  strongly  in  favour  of  forced  dilatation 
of  the  sphincter,  originated  by  Recamier,  in  the  treat- 
ment of  anal  fissure  ; in  fact  he  scarcely  admits  of  any 
other  method.  He  says  : 

“ The  cure  is  thus  complete  after  the  operation,  but 
it  is  not  a lasting  one,  relapses  often  occurring ; this  is 
another  argument  in  favour  of  the  neuralgic  nature  of 
the  complaint.” 

A post-mortem  examination  was  made  in  Paris  on  a 
girl,  who  died  of  cholera  within  a few  hours  of  having 
forcible  dilatation  made  for  the  cure  of  fissure.  The 
surgeon — whose  name  I have  forgotten — states  that 
none  of  the  fibres  of  the  sphincter  muscles  were  in  the 
least  degree  torn,  though  the  mucous  membrane  was 
slightly  lacerated. 

Although  I had  in  several  cases  employed  Dr  Dol- 
beau’s  method,  I found,  as  he  had  done,  relapses  were 

14 


210 


FISSURE  OF  THE  ANUS 


not  uncommon  and  I further  looked  upon  “ forcible” 
dilatation  as  a cruel  operation.  My  first  experience 
of  this  treatment  was  gained  in  Paris,  and  I will  describe 
literally  what  I saw,  and  it  was  so  repugnant  to  my 
feelings  that  I was  greatly  disinclined  to  it.  A male 
patient  was  brought  into  the  theatre  suffering  from 
fissure  of  the  anus.  The  surgeon  introduced  one  finger 
into  the  anus  and  then  another  until  he  gradually,  but 
with  much  pressure,  got  the  whole  hand  into  the 
rectum ; he  then  made  a fist  of  his  hand  and  forcibly 
drew  it  out.  The  cries  of  the  patient  were  really  heart- 
rending, and  six  or  seven  assistants  were  employed  in 
holding  him  down. 

Now,  during  the  past  four  years,  I have  repeatedly 
dilated  the  sphincter  for  the  cure  of  fissure,  and  as 
I do  it,  the  operation  is  not  violent  and  the  result  is 
on  the  whole  very  satisfactory.  The  patient  being 
thoroughly  placed  under  the  influence  of  an  anaesthetic, 
I introduce  my  two  thumbs,  one  after  the  other,  taking 
care  to  press  the  ball  of  one  thumb  over  the  fissure  and 
the  other  directly  opposite  to  it;  this  prevents  the  fissure 
from  being  torn  through  and  the  mucous  membrane 
stripped  off.  I now  gradually  separate  my  thumbs ; 
then  I repeat  the  stretching  in  the  opposite  direction, 
i.e.  at  right  angles  to  my  first ; then  in  other  directions, 
until  I have  gone  round  the  anus.  I then  apply  con- 
siderable pressure  to  the  sphincter  muscles  all  round, 
pulling  apart  the  anus  with  four  fingers,  two  on  each 
side,  and  kneading  the  muscles  thoroughly ; by  thus 
gently  pressing  and  pulling,  the  sphincters  completely 
give  way,  and  the  muscle,  previously  hard,  feels  like  a 
well-beaten  beef-steak  or  even  putty.  This  will  occupy 
at  least  five  or  six  minutes  to  do  thoroughly ; there  is 


FISSURE  OF  THE  ANUS 


211 


scarcely  more  than  a drop  or  two  of  blood  seen,  but 
you  can  see  that  the  anus  is  bruised,  and  for  a few  days 
extravasation  is  noticed,  the  part  gradually  undergoing 
the  changes  of  colour  usually  observed  in  any  bruise. 
This  operation  is  perfectly  safe  and  almost  painless. 
I place  in  the  rectum  a suppository  of  half  a grain  of 
morphia  and  apply  cold.  I am  bound  to  say  that 
since  I have  dilated  as  above  described,  1 have  never 
failed  to  cure  a patient. 


I saw,  with  Dr  Robert  Mitchell,  of  Lewisham,  a gentleman  of  more 
than  eighty,  who  suffered  greatly  from  a fissure  of  long  standing,  in 
conjunction  with  some  haemorrhoids.  He  was  too  old  to  allow  me  to 
press  a cutting  operation,  but  dilatation  perfectly  cured  him  in  eight 
days,  and  he  has  continued  in  comfort  until  now. 


I could  relate  a number  of  cases  in  which  dilatation 
has  cured  fissure  and  painful  ulcer,  as  well  as  obstinate 
constipation  from  contraction  of  the  sphincter  muscles, 
and  in  such  cases  I often  employ  it.  I can  remember 
that  the  late  Mr  Salmon  was  in  the  habit  of  treating 
constipation  by  passing  bougies,  gradually  increasing 
the  size,  until  a very  large  one  could  be  introduced ; I 
have  reason  to  know  he  was  successful.  He  used  the 
same  treatment  as  a preliminary  step  to  the  operation 
on  piles,  and  there,  again,  I am  sure  he  gained  much 
advantage  in  lessening  the  pain  after  the  operation — a 
result  which,  as  noticed  in  a previous  page,  can  be 
accomplished  by  dilatation.  There  are  still  cases  of 
fissure  and  ulcer  in  which  I prefer  the  knife,  and  shall 
continue  to  use  it ; but  I am  bound  to  say  my  con- 
fidence in  proper  dilatation  is  greatly  increased,  and  I 
am  sure,  when  properly  done,  it  is  very  successful, 
though  occasional  relapses  may  occur.  Some  years 


212 


FISSUEE  OF  THE  ANUS 


ago  I frequently  divided  the  sphincter  subcutaneously 
for  the  cure  of  fissure,  but  I have  ceased  to  practise 
this  operation  as  possessing  no  advantages  and  not 
being  certain  in  its  result. 


CHAPTER  XVI 


IMPACTION  OF  FiECES 

The  result  of  prolonged  constipation  may  be  a col- 
lection of  clayey  fasces  formed  in  the  caecum  or  in  any 
part  of  the  colon,  but  the  term  66  impaction  ” is  gene- 
rally used  when  the  accumulation  takes  place  in  the 
pouch  of  the  rectum  immediately  above  the  internal 
sphincter  muscle.  This  is  its  most  frequent  situation, 
and  here  a very  large  deposit,  more  or  less  globular  in 
shape,  is  often  found.  It  occurs  in  females  more  com- 
monly than  in  males : old  women,  and  women  shortly 
after  their  confinements,  being  especially  liable  to  it. 
In  aged  people  very  often  one  of  the  first  indications 
of  failing  nerve-power  is  loss  or  diminution  of  the  con- 
tractile force  of  the  colon  and  consequent  inaction  of 
the  bowels,  leading  to  impaction. 

I have  seen  some  cases  of  impaction  in  hysterical 
young  girls  and  in  middle-aged  females.  I have  also 
met  with  it  in  elderly  men,  but  until  recently  I never 
had  a well-marked  example  of  this  disorder  in  a young 
man,  but  I have  found  it  occur  more  than  once  in  chil- 
dren ; I saw  a little  boy,  only  three  years  of  age,  who 
had  a veritable  impaction  which  gave  a good  deal  of 
trouble,  but  when  it  was  removed  the  bowel  soon 
regained  its  tone,  and  regular  action  was  afterwards 
easily  kept  up. 


214 


IMPACTION  OF  FiEOES 


The  cause  of  the  accumulation  I believe  nearly 
always  to  be  primarily,  a loss  of  power  of  the  mus- 
cular coat  of  the  rectum.  This  loss  of  power  may 
have  been  produced  by  the  pressure  of  the  child’s  head 
during  a long  protracted  labour,  or  by  over-distension 
of  the  bowel  through  habitual  neglect  of  the  calls  of 
nature,  in  which  case  the  collection  may  be  the  result 
of  months’  costiveness,  and  the  condition  of  the  rectum 
much  resembles  that  of  a bladder  paralysed  from 
retention  of  urine. 

Spasm  of  the  sphincter  has  been  said  to  be  a cause 
of  impaction,  but  I have  more  often  thought  the  re- 
verse was  the  case,  and  the  impaction  the  cause  of  the 
spasm.  I must,  however,  acknowledge  that  spasm  is 
often  the  cause  of  the  constipation  which  is  the  fore- 
runner of  impaction.  In  impaction  spasm  of  the 
sphincter  always  exists,  in  some  instances  to  such  a 
degree  that  when  the  patient  strained  I have  observed 
the  anus  protrude  like  a nipple,  and  an  injection 
return  in  a fine  stream  as  if  coming  out  of  a squirt. 
I have  certainly  met  with  cases  of  idiopathic  spasm  of 
the  sphincter,  occurring  for  the  most  part  in  elderly, 
nervous,  single  women,  and  though  no  impaction  was 
present,  there  was  always  more  or  less  constipation. 

The  symptoms  of  impaction  are  not  uncommonly 
very  obscure,  and  the  malady  may  be  mistaken  for 
something  else.  I was  once  called  to  see  a lady 
labouring  under  impaction,  and  found  that  an  eminent 
physician  had  recently  declared  her  to  be  suffering  from 
neuralgia  of  the  bowel  and  had  ordered  her  quinine 
and  steel,  and  I have  heard  of  another  case  which  was 
treated  as  gout  in  the  rectum.  I have  met  with  several 
patients  who  were  supposed  to  be  the  subjects  of 


IMPACTION  OF  F2E0ES 


215 


malignant  disease  of  the  csecum  or  sigmoid  flexure  from 
the  fact  of  there  being  a tumour  present,  and  from  the 
patient’s  aspect,  which  is  frequently  very  suggestive  of 
cancer.  I had  a very  marked  case  of  impaction  in  a 
girl,  thirteen  years  of  age,  which  was  supposed  to  be 
enlarged  mesenteric  glands,  and  was  being  treated  with 
steel  and  cod-liver  oil.  I attended  a gentleman  who 
was  believed  by  his  physician  to  have  incipient  disease 
of  the  brain,  so  much  nervousness  and  hypochondriasis 
resulted  from  a very  loaded  colon  and  impacted  rectum. 
I had  a case  in  a young  lady  which  was  said,  by  more 
than  one  medical  man,  to  be  phthisis,  constant  cough 
being  present,  with  hectic  at  night,  and  much  emacia- 
tion. And  lastly,  a very  common  but  sad  error  is  often 
committed  ; these  patients  are  treated  for  diarrhoea  with 
tenesmus,  as  a considerable  fluid  discharge  from  the 
bowel  is  not  at  all  incompatible  with  great  retention  of 
solid  faeces. 

A very  interesting  case  was  sent  me  by  Dr  Frodsham.  The  patient 
was  an  elderly  person  from  the  country,  who  was  placed  under  Dr 
Frodsham’s  care.  She  had  been  for  a long  time  ill  with  severe  pains 
in  the  bowels  of  a colicky  character,  not  especially  restricted  to 
one  part  of  the  abdomen,  which  was  much  swollen.  No  tumour  could 
be  detected.  She  was  subject  to  hiccough  and  flatulence.  This  was 
attended  with  dyspnoea  and  palpitation  of  the  heart.  She  had  on 
several  occasions  fainted  away,  and  fears  were  entertained  that  the 
heart  was  not  sound.  Always  or  nearly  so  in  conjunction  with  the 
abdominal  pain  she  had  diarrhoea,  copious  coloured  watery  stools ; for 
the  correction  of  this,  she  had  been  prescribed  opium  with  carmina- 
tives, a few  doses  generally  gave  her  much  relief.  Her  appetite  was 
bad,  and  she  had  frequent  retching  and  sometimes  vomiting.  Dr 
Frodsham  not  being  satisfied  with  the  case  sent  her  to  me.  She  was 
fifty  years  of  age,  not  ill-nourisbed,  her  face  wore  an  anxious  expression, 
and  the  complexion  was  muddy.  Her  general  symptoms  had  existed 
over  two  years.  The  tongue  was  quite  clean  and  too  red.  On  exami- 
nation the  heart  and  lungs  were  found  sound.  The  abdomen  was  much 
distended  and  the  diaphragm  forced  upwards,  causing  dyspnoea  when 


216 


IMPACTION  OF  FiEOES 


sbe  lay  down.  The  abdomen  was  globular,  and  there  was  no  particular 
prominence  in  any  one  part.  The  skin  was  not  shiny ; on  manipulation 
the  abdomen  felt  doughy ; it  was  also  tender  so  that  she  could  not  bear 
much  kneading,  but  after  a little  pressure  the  transverse  colon  started 
into  action,  and  it  was  felt  to  be  very  large.  A flexible  tube  was  easily 
passed  eighteen  inches,  and  on  withdrawal,  it  was  in  parts  smeared 
with  faeces ; on  introducing  the  finger  into  the  rectum  the  latter  was 
found  filled  with  clayey  faeces.  The  diagnosis  was  great  faecal  accumu- 
lation and  slight  impaction.  I ordered  her  a pill  of  podophyllin, 
calomel,  belladonna,  and  pil.  colocynth  co.  three  times  in  the  day,  and, 
every  morning,  an  injection  of  a pint  and  a half  of  thin  gruel  with  two 
ounces  of  fresh  ox  gall  in  it.  On  the  third  morning  of  this  treatment 
she  passed  an  enormous  motion,  more  than  enough  to  fill  an  ordinary 
chamber  utensil.  The  same  pills  and  enema  were  continued  now  every 
day,  and  were  followed  by  several  enormous  evacuations.  I really  may  say 
that  the  quantity  of  faecal  matter  she  parted  with  would  to  most  persons 
appear  incredible.  After  ten  days  the  medicine  was  changed  to  a com- 
bination of  laxatives  and  tonics,  which  she  continued  for  some  time, 
but  at  the  termination  of  three  weeks  all  her  discomforts  were  gone  and 
she  was  quite  slender  as  regards  the  abdomen. 

In  the  history  of  these  cases  it  is  not  rare  to  find 
that  severe  pains  have  been  experienced  in  the  right 
lumbar  and  left  inguinal  regions ; this  symptom  points 
to  the  fact  that  the  caecum  had  been  the  seat  of  obstruc- 
tion and  distension,  and  that  when  this  was  removed 
the  faeces  again  lodged  in  the  rectal  pouch.  The  sym- 
ptoms of  impaction  might  be  expected  to  be  generally 
those  of  obstruction,  and  resemble  in  many  respects 
those  of  stricture  of  the  rectum,  and  sometimes  this 
is  so,  but  the  absence  of  any  jelly-like  or  coffee-ground 
discharge  is  an  important  point  to  be  noticed  in  the 
diagnosis.  The  patient  often  really  complains  of  a 
tendency  to  diarrhoea,  liquid  motions  being  frequently 
passed,  especially  after  an  aperient,  but  without  any 
sense  of  relief,  and  on  assuming  the  erect  position, 
straining,  severe,  continuous  and  irresistible,  takes 
place.  On  lying  down  this  generally  gradually  passes  off. 


IMPACTION  OF  FJ1CES 


217 


Dyspepsia,  irritability  of  temper,  nervousness  and 
despondency,  tbe  patient  supposing  herself  to  be  suf- 
fering from  an  incurable  malady,  a very  muddy-yellow 
skin  suggestive  of  malignant  disease,  morning  vomiting, 
and  a loathing  of  all  food  as  soon  as  a few  mouthfuls 
have  been  taken,  excessive  and  very  painful  thirst,  are 
among  the  common  symptoms  of  this  disorder.  A 
peculiar  ringing,  barking  cough,  particularly  in  women, 
and  also  night  sweats,  are  not  uncommon.  In  both 
men  and  women  I have  seen  very  obstinate  retention 
of  urine  caused  by  impaction.  All  these  symptoms 
may  continue  more  or  less  urgent  for  months,  and 
aperients  and  injections  may  be  given  without  affording 
more  than  temporary  relief. 

When  examining  a patient,  if  you  make  careful 
palpation  over  the  abdomen,  tumours  may  be  felt  in 
the  caecum,  the  transverse  colon,  or  the  sigmoid 
flexure ; under  any  circumstances,  in  the  majority  of 
cases,  if  you  look  at  the  anus  you  will  see  that  it  is 
nipple-shaped,  and  if  you  feel  around  the  anus  you  will 
find  the  sphincter  muscle  tightly  contracted  and  almost 
as  hard  as  a piece  of  wood.  It  is  only  with  difficulty 
that  you  can  introduce  your  finger  into  the  bowel,  and 
having  done  so,  you  will  find  a ball  of  hardened  clayey 
faeces  filling  up  the  rectal  pouch.  This  ball  I have  seen 
almost  as  large  as  a foetal  head,  and  quite  movable,  so 
as  to  admit  of  liquid  or  thin  motion  passing  round  by 
the  sides  of  it,  thus  giving  rise  to  the  impression  that 
diarrhoea  rather  than  constipation  existed.  So  decep- 
tive is  the  feeling  this  mass  gives  to  the  finger,  that  I 
have  more  than  once  thought  I must  be  touching  a 
tumour ; and  I have  been  called  in  consultation  several 
times  by  medical  men,  who  had  discovered  the  impac- 


218 


IMPACTION  OF  FAECES 


tion,  but  could  not  believe  that  what  they  felt  was 
only  a collection  of  fasces. 

In  bad  cases  you  must  commence  the  treatment  of 
this  malady  by  thoroughly  breaking  up  the  ball  of 
faeces. 

The  best  mode  of  accomplishing  this  is  first  to  put 
the  patient  under  an  anaesthetic  and  then  forcibly  but 
slowly  dilate  the  sphincters  by  introducing  both  your 
forefingers  well  oiled,  and  separating  them  in  the 
antero-posterior  direction,  then  again  towards  the 
tuberosities  of  the  ischia.  You  need  not  tear  the 
mucous  membrane,  but  you  so  stretch  the  muscles  as 
to  paralyse  them  for  a time  ; this  done  you  can  get  at 
the  interior  of  the  rectum  without  any  difficulty,  and 
break  up  the  mass  with  your  finger,  or  a lithotomy 
scoop,  or  the  handle  of  an  old-fashioned  silver-spoon. 
The  spasm  of  the  sphincters  being  thus  overcome,  you 
can  do  a great  deal  at  one  sitting,  in  fact  quite  empty 
the  rectum. 

After  you  have  thoroughly  broken  up  the  impacted 
mass  you  may  administer  injections  of  soap  and  water 
and  oil,  and  in  this  way  you  will  often  get  rid  of  enorm- 
ous quantities  of  faeces.  When  the  ball  occupying  the 
rectal  pouch  is  cleared  away,  other  masses  generally 
come  down,  and  I have  seen  as  much  as  would  fill  two 
or  three  chamber  utensils  passed  at  one  operation. 

I have  found,  in  several  instances,  the  rectum  so 
much  dilated  that  the  upper  part  of  the  bowel  opened 
into  the  pouch  like  a pipe  into  a bladder. 

It  is  often  a considerable  time  before  the  rectum 
recovers  its  power  after  its  great  distension,  and, 
therefore,  you  must  take  care  that  no  reaccumulation 
takes  place.  Injections  of  cold  water,  kneading  the 


IMPACTION  OF  FiECES 


219 


abdomen,  and  tbe  exhibition  of  the  compound  decoction 
of  aloes  with  nux  vomica,  will  be  found  useful.  As 
soon  as  the  bowel  is  thoroughly  cleared  out  I am  in 
the  habit  of  prescribing  the  following  pill,  which  is 
very  effective  in  restoring  power  to  the  colon  and 
rectum,  thus  inducing  a regular  action  of  the  bowels : 
— Ferri  Sulph.  Exsicc.  gr.  J,  Quinise  Sulph.  gr.  j, 
Extracti  Nucis  Vomicae  gr.  Ext.  Aloes  aq.  gr.  j, 
Extr.  Taraxaci  q.  s.  ut  fiat  pil.,  take  one  three  times 
in  the  day  after  meals.  Faradisation  is  most  advan- 
tageous in  these  cases. 

Persons  of  sedentary  habits  are  especially  liable  to 
these  attacks,  exercise  in  the  open  air  must  therefore 
be  taken  daily. 

The  diet  should  not  be  too  liberal.  An  elderly  lady 
was  a patient  of  mine  on  three  occasions  with  impac- 
tion and  loaded  caecum,  and  I am  sure  it  was  because 
she  was  a very  hearty  eater  and  never  took  any  exer- 
cise. I could  neither  persuade  her  to  walk  more  nor 
to  eat  less. 

Impactions  have,  as  I have  mentioned,  been  often 
mistaken  for  malignant  abdominal  tumours,  but  the 
diagnosis  is  usually  not  difficult  if  observations  be 
carefully  made.  There  are  two  points  of  distinction 
which  may  always  be  noticed : 1st.  An  examination 
from  time  to  time  will  show  that  the  tumour  differs  in 
size  and  shape — this  the  patient  will  often  be  the  first 
to  remark.  2nd.  A very  careful  manipulation  will 
detect  that  the  tumour  is  irregularly  soft  and  has  a 
decidedly  doughy  feeling.  When  the  tumour  is  in 
the  sigmoid  flexure  or  rectum  the  introduction  of  the 
finger  will  at  once  clear  up  the  doubt,  if  there  be  any. 

Concretions  in  the  bowel  are  rarer  than  impactions, 


220 


CONCRETIONS  IN  THE  RECTUM 


and  they  differ  from  these  in  that  they  are  often  formed 
round  some  foreign  body  and  are  usually  cylindrical 
in  shape.  Concretions  consist  of  animal  and  vege- 
table fibres  matted  together  around  a nucleus  which 
may  vary  according  to  circumstances.  In  one  case  a 
quantity  of  human  hair  formed  the  core ; the  patient 
had  been  in  a lunatic  asylum,  and  in  a fit  of  mania  had 
swallowed  the  hair.  She  had  suffered  from  attacks  of 
intestinal  obstruction  for  months,  and  she  always  said 
there  was  something  in  the  bowel  which  would  not 
pass  through  the  anus.  She  was  brought  to  me  at  St 
Mark’s  Hospital.  I forcibly  dilated  her  sphincter 
and  with  a lithotomy  scoop  and  my  finger  succeeded, 
after  some  trouble,  in  removing  a conical-shaped  mass 
more  than  six  inches  in  length  by  two  inches  and  a 
quarter  in  diameter ; it  was  covered  with  pus  and 
extremely  fetid.  On  cutting  through  it,  as  I have 
mentioned,  the  centre  was  found  to  consist  of  human 
hair. 

Another  patient  of  mine,  an  elderly  gentleman, 
had  an  obstruction  of  the  rectum  which  I thought 
was  an  ordinary  impaction,  but  it  was  not  globular  in 
form,  and  when  I tried  to  break  it  up  I could  not  do 
so,  as  it  slipped  away  and  was  too  tenacious.  After 
dilating  the  sphincters  I was  able  to  get  hold  of  it 
with  a pair  of  lithotomy  forceps  and  gradually  draw  it 
out.  The  nucleus  was  a large  biliary  calculus,  and 
around  it  were  vegetable  and  animal  fibres  and  dried 
faeces ; the  whole  was  covered  by  a thick  coating  of 
mucus  and  pus.  Eighteen  months  before,  he  had 
suffered  from  an  attack  of  gall-stones,  and  no  doubt 
this  calculus  had  then  lodged  in  the  bowel,  probably 
in  one  of  the  sacculi  of  the  colon. 


CONCRETIONS  IN  THE  RECTUM 


221 


I have  already  related  another  case  of  this  kind. 

One  more  case  I will  record,  as  it  is  peculiar ; here  a 
sovereign  formed  the  nucleus.  The  patient,  a woman, 
came  to  St  Mark’s  Hospital  suffering  from  stricture 
of  the  rectum ; when  I dilated  the  stricture  I found  a 
large  mass  above  it.  Purgatives  and  enemata  not 
effecting  its  removal,  I eventually  brought  it  down 
with  a scoop  and  my  finger;  it  was  cylindrical  in 
form.  On  tearing  it  up  to  examine  its  structure  I 
found  in  its  centre  the  coin  I have  mentioned.  Quite 
fifteen  months  before,  the  woman  had  swallowed  a 
sovereign,  and  she  had  sought  for  it  in  her  motions,  but 
failed  to  find  it ; she  had  not  any  idea  that  it  had  not 
passed.  I think  it  very  likely  that  at  that  time  she 
had  incipient  stricture  of  the  rectum,  and  consequently 
the  piece  of  money  did  not  escape  from  the  bowel. 

I will  not  occupy  more  space  on  this  subject ; the 
cases  are  somewhat  rare  and  the  treatment  simple 
enough.  When  the  mass  comes  down  near  the  anus  it 
must  be  removed  bodily ; you  will  find  it  so  tenacious 
that  you  cannot  break  it  up  like  an  ordinary  impaction. 
Unless  you  dilate  the  sphincter  you  will  have  very  great 
difficulty  in  extracting  these  concretions ; in  fact,  it  will 
be  almost  impossible  to  do  so. 

It  is  very  curious  how,  sometimes,  small  substances 
fail  to  traverse  the  alimentary  canal  safely,  and  how, 
at  other  times,  very  large  bodies  pass  without  pro- 
ducing any  severe  or  dangerous  symptoms.  There  are 
cases  related  by  Sir  James  Paget,  Mr  Henry  Smith,  and 
others,  where  a considerable  portion  of  a set  of  false 
teeth  mounted  in  gold  was  swallowed  and  not  arrested 
anywhere  in  the  intestines. 

There  is  one  thing  we  should  recollect  when  such  a 


222 


CONCRETIONS  IN  THE  RECTUM 


case  comes  before  us — that  is,  never  give  a purge.  You 
may  tell  your  patient  to  eat  very  freely  of  solid 
material,  such  as  suet-pudding,  bread,  and  the  like,  so 
as  to  form  full-sized  cohesive  motions. 

These  cases  must  not  teach  us  to  lightly  estimate  the 
danger  of  swallowing  foreign  bodies ; many  cases  are 
on  record  where  such  a simple  matter  as  a cherry  stone 
has  caused  death,  by  setting  up  ulceration  and  perfo- 
ration of  the  bowel,  usually  the  caecum  or  vermiform 
appendix. 

I saw  some  time  back  a case,  with  Dr  Nash  and 
Mr  Clover,  of  a fine  young  lad  who  lost  his  life  from 
peritonitis  caused  by  perforation  of  the  appendix 
vermiformis.  The  foreign  body  appeared  to  be  a small 
portion  of  wood,  around  which  faecal  matter  had 
deposited,  augmenting  its  size  to  about  that  of  a small 
date  stone,  but  pointed  at  each  end.  The  symptoms 
were  at  first  not  very  pronounced,  but  the  fever  was 
soon  great  and  accompanied  by  much  delirium.  No 
operative  interference  was  resorted  to,  the  diagnosis 
being  that  the  obstruction  to  action  of  the  bowels  was 
caused  by  peritonitis,  the  result  of  probable  perfora- 
tion of  the  crncum  or  its  appendix.  The  post-mortem 
verified  the  diagnosis. 


CHAPTER  XYII 

ULCERATION  AND  STRICTURE  OF  THE  RECTUM 

Ulceration  extending  above  tbe  internal  sphincter, 
and  frequently  situated  entirely  above  that  muscle,  is 
not  a very  uncommon  disease ; it  inflicts  great  misery 
upon  the  patient,  and  if  neglected,  leads  to  conditions 
quite  incurable,  and  the  patient  dies  of  exhaustion 
unless  extraordinary  means  are  resorted  to.  In  the 
earlier  stages  of  the  malady,  careful,  rational,  and  pro- 
longed treatment  is  often  successful,  and  the  patient 
is  restored  to  health ; I wish  I could  say  the  same  of 
the  severe  and  long-standing  cases.  Ulceration  of  the 
rectum  can  be  mistaken  only  for  malignant  disease ; 
but  when  the  symptoms  are  carefully  considered,  and 
the  finger  is  well  educated,  there  can  but  very  occa- 
sionally be  any  error  in  diagnosis  committed.  As  the 
earlier  manifestations  are  fairly  amenable  to  treatment, 
it  is  of  the  utmost  importance  that  the  disease  should 
be  recognised  early.  Unfortunately,  it  rarely  is  so ; the 
symptoms  are  obscure  and  insidious,  the  suffering  at 
first  but  slight,  and  thus  the  patient  deceives,  not  only 
himself,  but  his  medical  attendants,  by  the  little  heed 
he  gives  to  the  complaint. 

In  the  majority  of  these  cases  the  earliest  symptom 
is  morning  diarrhoea,  and  that  of  a peculiar  character ; 


224 


STRICTURE  OF  THE  RECTUM 


in  my  opinion  it  is  quite  indicative  of  the  disease,  and 
can  be  confounded  only  with  similar  symptoms  due  to 
cancer.  The  patient  will  tell  you  that  the  instant  he  gets 
out  of  bed  he  feels  a most  urgent  desire  to  go  to  stool;  he 
does  so,  but  the  result  is  not  satisfactory.  What  he 
passes  is  generally  wind,  a little  loose  motion,  and  some 
discharge  resembling  “ coffee  grounds  ” both  in  colour 
and  consistency ; occasionally  the  discharge  is  like  the 
“ white  of  an  unboiled  egg ; or  f£  a jelly-fish  ; ” more 
rarely  there  is  matter.  The  patient  in  all  probability  has 
tenesmus,  and  does  not  feel  relieved ; there  is  a some- 
what burning  and  uncomfortable  sensation,  but  not 
actual  pain ; before  he  is  dressed  very  likely  he  has 
again  to  seek  the  closet ; this  time  he  passes  more 
motion,  often  lumpy,  and  occasionally  smeared  with 
blood.  It  may  also  happen  that  after  breakfast,  hot 
tea  or  coffee  having  been  taken,  the  bowels  will  again 
act ; after  this  he  feels  all  right,  and  goes  about  his 
business  for  the  rest  of  the  day,  only,  perhaps,  being 
occasionally  reminded  by  a disagreeable  sensation  that 
he  has  something  wrong  with  his  bowel.  Not  by  any 
means  always,  but  at  times,  the  morning  diarrhoea  is 
attended  with  griping  pain  across  the  lower  part  of  the 
abdomen  and  great  flatulent  distension.  When  a 
medical  man  is  consulted  the  case  is,  in  all  probability, 
and  quite  excusably,  considered  one  of  diarrhoea  of  a 
dysenteric  character,  and  treated  with  some  stomachic 
and  opiate  mixture,  which  affords  temporary  relief. 
After  this  condition  has  lasted  for  some  months,  the 
length  of  this  period  of  comparative  quiescence  being 
influenced  by  the  seat  of  the  ulceration  and  the  rapidity 
of  its  extension,  the  patient  begins  to  have  more 
burning  pain  after  an  evacuation,  there  is  also  greater 


ULCERATION  OF  THE  RECTUM 


225 


straining  and  an  increase  in  tlie  quantity  of  discharge 
from  the  bowel ; there  is  now  not  so  much  jelly-like 
matter,  but  more  pus — more  of  the  coffee-ground  dis- 
charge, and  blood.  The  pain  suffered  is  not  very  acute, 
but  very  wearying ; described  as  like  a dull  toothache, 
and  it  is  induced  now  by  much  standing  about  or 
walking.  At  this  stage  of  the  complaint  the  diarrhoea 
comes  on  in  the  evening  as  well  as  the  morning,  and  the 
patient’s  health  begins  to  give  way,  only  triflingly  so, 
perhaps,  but  he  is  dyspeptic,  loses  his  appetite,  and  has 
pain  in  the  rectum  during  the  night,  which  disturbs  his 
rest ; he  also  has  wandering  and  apparently  anomalous 
pains  in  the  back,  hips,  down  the  leg,  and  sometimes 
in  the  penis.  There  is  yet  another  symptom  present 
in  the  later  stages,  marking  the  existence  of  some  slight 
contraction  of  the  bowel,  viz.  alternating  attacks  of 
diarrhoea  and  constipation,  and  during  the  attacks  of 
diarrhoea  the  patient  passes  a very  large  quantity  of 
faeces.  These  seizures  are  attended  with  severe  colicky 
pains  in  the  abdomen,  faintness,  and  not  unfrequently 
sickness. 

As  the  ulceration  extends,  attempts  at  healing  take 
place ; these  result  in  infiltration  and  thickening  of  the 
submucous  and  muscular  tissues,  and  consequent 
diminution  of  the  calibre  of  the  bowel,  so  that  real 
stricture  of  various  forms  supervenes.  Coincident  with 
all  this  there  results  a gradual  loss  of  the  contractile 
power  of  the  rectum,  and  almost  complete  immobility, 
so  that  the  lower  part  of  the  gut  is  converted  into  a 
passive  tube  through  which  the  fasces,  if  fluid,  trickle  ; 
but  if  solid,  they  stick  fast  until  pushed  through  by  fresh 
formations  above  them.  Invariably  also  there  is  loss 
of  power  in  the  sphincters.  When  diarrhoea  is  present 

15 


226 


STRICTURE  OF  THE  RECTUM 


the  patient  has  little  or  no  control  over  his  motions. 
Usually  by  this  time  abscesses  have  formed,  or  are  in 
process  of  formation,  and  these  breaking  soon  become 
fistulas.  I have  seen  persons  with  as  many  as  eight 
external  orifices,  some  situated  three  inches  or  more 
from  the  anus. 

On  examining  these  cases  of  ulceration  of  the  rectum, 
various  conditions  may  be  noticed  according  to  the 
stage  to  which  the  disease  has  advanced.  In  the 
earlier  period  you  may  often  feel  an  ulcer  situated 
dorsally  about  one  and  a half  inches  from  the  anus, 
oval  in  form,  perhaps  an  inch  long  by  half  an  inch 
wide,  surrounded  by  a raised  and  sometimes  hard 
edge ; there  is  acute  pain  caused  on  touching  it,  and  it 
may  be  readily  made  to  bleed.  With  a speculum  you 
can  distinctly  see  the  ulcer,  the  edges  well  marked,  the 
base  greyish  or  very  red  and  inflamed  looking,  the  sur- 
rounding mucous  membrane  being  probably  healthy; 
in  the  neighbourhood  of  the  ulcer  may  often  be  felt 
some  lumps,  which  are  either  gummata  or  enlarged 
rectal  glands.  This  is  the  stage  in  which  the  disease  is 
often  curable,  as  I shall  show  when  speaking  of  treat- 
ment. Later  in  the  progress  of  the  malady,  you  will 
observe  deep  ulcers,  with  great  thickening  of  the 
mucous  membrane,  often  also  roughening  to  a con- 
siderable extent,  as  though  the  mucous  membrane  had 
been  stripped  off.  At  this  stage  you  generally  notice, 
outside  the  anus,  swollen  and  tender  flaps  of  skin, 
shiny,  and  covered  with  an  ichorous  discharge ; these 
flaps  are  commonly  club-shaped,  and  are  met  with  also 
in  malignant  disease ; but  in  the  early  development  of 
the  disease  no  ulceration  is  found  near  the  anus  nor  at 
the  aperture.  It  is  in  private  practice  that  we  have  the 


ULCERATION  OF  THE  RECTUM 


227 


best  opportunity  of  seeing  these  cases  early,  and  I most 
positively  repeat  that  the  large  majority  do  not  com- 
mence by  any  manifestation  at  the  anus,  such  as 
growths  or  sores — occasionally  a fissure  may  be  the 
first  lesion,  and  the  ulceration  extend  from  the  wound 
made  in  attempting  to  cure  it — this  is,  however,  the 
exception  to  the  rule,  and  I will  further  on  relate  some 
cases  to  show  that  what  I have  stated  is  correct.  So 
definite  is  this  external  appearance  in  long-standing 
disease,  that  one  glance  is  sufficient  to  enable  an  expert 
to  predicate  the  existence  of  either  cancer  or  severe 
ulceration ; these  external  enlargements  are  the  result 
of  the  ulceration  going  on  in  the  bowfel,  and  the  irrita- 
tion caused  by  almost  constant  discharge.  The  ulcera- 
tion may  be  confined  to  a part  of  the  circumference  of 
the  bowel,  or  it  may  extend  all  round,  and  for  some 
distance,  but  not  usually  for  more  than  four  inches  up 
the  rectum.  It  also  probably  will  have  travelled 
downwards  close  to  the  anus,  and  then  the  pain  is 
sure  to  be  very  severe,  because  the  part  is  more  sensi- 
tive and  more  exposed  to  external  influences  and 
accidents. 

When  the  disease  has  reached  this  stage,  of  course 
stricture  and  most  probably  fistulse  will  be  present, 
as  I have  already  mentioned  ; and  possibly,  but  not 
frequently,  perforation  into  the  bladder,  into  the  vagina, 
or  the  peritoneal  cavity,  may  occur.  The  state  of  the 
patient  is  now  most  lamentable ; his  or  her  aspect 
resembles  that  of  a sufferer  from  malignant  disease, 
and  no  remedy  short  of  lumbar  colotomy  offers  much 
chance  of  even  prolonging  life.  You  may  relieve 
these  patients,  but  can  rarely  do  more  ; a cure  can 
scarcely  be  expected.  I have  seen  ulceration  utterly 


228 


STRICTURE  OF  THE  RECTUM 


destroy  both  the  anal  sphincters,  so  that  the  anns  was 
but  a deep  ragged  hole.  Here  is  such  a case  which  was 
under  my  care  at  St  Mark’s  Hospital. 

Matilda  G — , admitted  under  my  care  January,  1871.  She  is  a 
married  woman,  twenty- eight  years  of  age.  Five  years  ago  she  was  a 
patient  of  mine  with  stricture  and  ulceration.  She  went  on  tolerably 
well,  and  continued  so  up  to  about  eighteen  months  back  ; since  then 
she  has  suffered  much ; she  had  constant  pain  and  discharge  from  the 
bowels ; she  either  has  constipation  or  diarrhoea.  There  is  entire  incon- 
tinence of  fseces.  The  straining  and  bearing  down  are  very  distressing ; 
her  aspect  is  worn  and  sallow;  she  is  not  very  emaciated ; there  is  no 
evidence  of  syphilis  or  consumption.  On  examination  a large,  ragged 
deep  hole  is  seen  instead  of  an  anus ; it  is  surrounded  by  swollen  flaps 
of  skin,  two  of  which  are  perforated  by  fistulse ; the  hole  measures 
about  two  inches  each  way,  and  there  is  not  a vestige  of  sphincter 
muscle  left.  On  introducing  the  finger  into  the  bowel,  it  is  found  quite 
blocked  up  by  contraction  and  thickening ; only  a very  small  aperture 
can  be  felt,  but  into  this  the  end  of  the  finger  cannot  be  passed.  Chloro- 
form being  given,  she  strained  down  so  violently  that  the  strictured 
portion  of  the  bowel  was  forced  outside,  so  that  the  ulceration  and 
stricture  could  be  plainly  seen.  The  aperture  was  not  larger  than  a 
No.  10  male  catheter.  I saw  this  patient  over  and  over  again,  she  was 
always  benefited  by  treatment  but  not  cured,  at  length  she  died  in  the 
workhouse. 

Years  may  bave  elapsed  before  tbe  dreadful  condi- 
tion I have  been  describing  has  been  brought  about, 
but  it  is  one  we  only  too  frequently  see  at  St  Mark’s. 

Patients  suffering  from  ulceration  and  stricture  are 
very  liable  to  attacks  of  a low  form  of  peritonitis, 
attended  with  considerable  abdominal  pain,  often  in- 
tense for  a short  period.  There  are  generally  one  or 
more  spots  that  are  tender  on  pressure ; there  is  tym- 
panitis, often  vomiting,  especially  on  first  assuming  the 
erect  position  in  the  morning,  and  generally  the  pain 
is  brought  on  by  standing  or  moving  about ; these 
attacks  are  sure  to  end  in  diarrhoea.  The  treatment 
should  be  perfect  rest  in  bed,  spoon  diet,  and  opium 


ULCERATION  OF  THE  RECTUM 


229 


may  be  given  freely;  fomentations  relieve  tbe  pain, 
but  I have  not  seen  any  benefit  result  from  counter- 
irritation. I have  often  found  that  calomel  and  opium 
given  for  some  time  is  advantageous  in  these  cases. 

When  making  a post  mortem  examination  in  such 
cases  I have  observed  effusion  into  the  peritoneal 
cavity,  and  often  considerable  old  and  recent  adhe- 
sions between  the  intestines ; the  peritoneum  is  also 
thickened.  In  bad  ulceration  you  see  what  great 
destruction  of  tissue  has  taken  place.  I have  found 
the  whole  of  the  rectum  and  sigmoid  flexure  involved 
in  ulceration,  and  great  thickening  and  contraction  of 
the  calibre  of  the  bowel,  caused  by  the  attempts  at 
repair  in  various  parts.  The  connective  tissue  here 
and  there  is  so  removed  as  to  leave  large  bridges  of 
indurated  muscle  and  roughened  mucous  membrane ; 
and  there  is  ulceration,  so  deep  in  places  that  perfora- 
tion must  have  occurred  but  for  the  adhesions  kindly 
made  by  nature  to  the  adjacent  parts.  In  other  situa- 
tions the  muscular  coat  is  laid  quite  bare,  and  I have 
seen  more  than  one  case  in  which  necrosis  of  the 
sacrum  had  taken  place. 

The  following  table  of  seventy  cases  which  have 
been  under  my  care  at  St  Mark’s  Hospital  exhibits, 
I think,  many  points  worthy  of  consideration. 


230  STRICTURE  OE  THE  RECTUM 


Seventy  Gases  of  Ulceration  and  Stricture  of  the  Rectum 
taken  from  Mr  Allingham’s  Practice  at  St  Mark’s 
Hospital. 


No. 

Age. 

Sex. 

Constitutional 
syphilis  or  not. 

Stricture  and  ulceration, 
where  found. 

Complications  and 
observations. 

1 

27 

F. 

Yes,  tertiary 

Stricture  2 inches  up ; 
ulceration  above  and 
below 

Fistula ; mucous  tuber- 
cles ; primary  infec- 
tion 5 years  since. 

. 2 

45 

F. 

Yes,  nodes 

Ulceration  from  anus  ; 
stricture  2 inches 

Sores  on  labia  ; fistula; 
primary  symptoms  5 
years  ago. 

3 

39 

F. 

Severe  cons, 
syph. 

Stricture  impermeable 
high  up 

Recto-vaginal  fistula ; 
colotomy ; lived  18 
months. 

4 

30 

F. 

No  history  or 
appearance 

Severe  ulceration  and 
stricture  2 inches 
from  anus 

No  complication  ; out- 
side parts  normal. 

5 

20 

F. 

No  syphilis ; 
struma 

Small  ulcer ; stricture 
li  inch ; ulceration 
above  stricture 

Outward  parts  quite 
normal;  hymen  pre- 
sent ; under  treat- 
ment 8 years;  died, 
exhaustion. 

6 

26 

F. 

Cons,  syph.; 
nodes  on 

forehead 

Stricture  1|  inch;  hy- 
pertrophy of  nymphse 

Ulceration  very  high ; 
colotomy  3 years  ago ; 
now  living. 

7 

36 

F. 

No  history  of 
syph. 

Stricture  2 inches  ; ul- 
ceration high  up 

Fistulse  in  all  directions, 
from  which  great  in- 
duration; colotomy; 
success. 

8 

44 

F. 

Cons.  syph.  (8 
years) 

Stricture  3 inches  long 
^ inch  from  anus 

No  complications ; co- 
lotomy successful. 

9 

37 

F. 

No  symptoms 
of  syph.  nor 
history 

Extensive  ulceration ; 
two  strictures  high  up 

Attempted  colotomy 
(right  side) ; death 
56  hours. 

10 

25 

F. 

Syphilis  well 
marked 

Stricture  l£  inch  from 
anus; ulceration  above 
and  below ; hardness 

Large  flaps  of  skin  out- 
side, and  fistula. 

11 

21 

F. 

Ditto 

Stricture  2 inches  from 
anus ; severe  ulcera- 
tion 

Recto-vaginal  fistula ; 
syphilis  7 years  at 
least. 

12 

28 

F. 

Probably. 

Sore  throat 
now 

Stricture  just  within 
reach  of  finger;  no 
ulceration  between 
anus  and  stricture 

Recto-vaginal  fistula ; 
anus  not  affected. 

13 

34 

F. 

No  symptoms 
or  history  of 
syph. 

Stricture  two  inches ; 
much  ulceration 

Fistula ; no  disease  of 
anus ; came  on  as  ab- 
scess. 

14 

28 

F. 

Cons.  syph. 

Stricture  1|  inch  from 
anus ; ulceration 

above 

Anus  normal ; syphilis 
12  years ; had  treat- 
ment. 

15 

37 

F. 

No  symptoms 
or  history 

Stricture  2^  inches ; 
bad  ulceration  ^above 
and  below  stricture 

Fistula  both  sides  of 
anus ; large  flaps  of 
hypertrophic  skin ; 
discharging. 

ULCERATION  OF  THE  RECTUM 


281 


No. 

Age. 

Sex. 

Constitutional 
syphilis  or  not. 

Stricture  and  ulceration, 
where  found. 

Complications  and 
observations. 

16 

36 

F. 

No  symptoms 
or  history 

Stricture  1 J inch ; ul- 
ceration near  anus 

Large  fibroid  polypus ; 
easy  cure 

17 

34 

F. 

Cons.  syph. 

Stricture  1£  inch;  ul- 
ceration deep  above 
and  below  stricture 

Dorsal  fistula  ; anus 
normal;  syphilis  18 
mos. ; rash  scaly,  and 
ulceration  on  tongue. 

18 

29 

F. 

None 

Simple  stricture  2 inches 
from  anus ; much  in- 
duration but  no  ulce- 
ration 

No  internal  abnorma- 
lity ; division  and 
lasting  cure. 

19 

40 

F. 

Cons.  syph. 

Ulceration  commencing 
1 inch  above  anus, 
stricture  2 inches 

Anus  natural. 

20 

20 

F. 

Ditto 

Tight  stricture 2 inches; 
ulceration 

Mucous  tubercles ; hy- 
pertrophied nymphse. 

21 

30 

F. 

No  history  of 
syph. 

Very  little  stricture  2 
inches ; superficial 
ulceration 

Verrucse;  no  sores; 
speedy  cure. 

22 

42 

F. 

Syphilis  well 
marked 

Stricture  1 inch  up ; 
ulceration  severe  and 
deep 

Fistula ; great  indura- 
tion and  swollen 
lumps  around  anus. 

23 

28 

F. 

None 

Annular  cord-like  stric- 
ture 2 inches;  ulcer- 
ation near  anus 

No  complication. 

24 

39 

F. 

Cons.  syph. 

Stricture  lg  inch  from 
anus ; not  much  ul- 
ceration 

Large  superficial  sore  in 
perineum,  extending 
into  anus ; fistula. 

25 

24 

F. 

None 

Stricture  2 inches,  dense 
and  long;  ulceration 
severe 

Recto-vaginal  fistula, 
commenced  alter 
childbirth ; colotomy, 
success. 

26 

53 

F. 

Cons.  syph. 

Stricture  tight;  no  ulce- 
ration above  or  below 

Fistula  in  ano;  syphilis 

5 years. 

27 

27 

F. 

None 

Stricture  just  inside 
anus ; no  ulceration  ; 
cure  by  incision  and 
dilatation 

No  complication. 

28 

25 

F. 

Cons.  syph. 

Strictui’e  2 inches  from 
anus ; ulceration  be- 
low and  above 

Syphilitic  rash  and 
sores ; 9 years  of 

syphilis. 

29 

33 

F. 

None 

Stricture  2 inches  from 
anus ; ulceration  se- 
vere 

Fistula  in  ano ; been 
operated  upon  several 
times. 

30 

22 

F. 

None 

Stricture  annular,  1^ 
inches  up ; ulceration 
severe 

Procidentia  recti ; a 
curious  case,  it  comes 
through  the  contrac- 
tion. 

31 

28 

F. 

Cons.  syph. 

Stricture  severe  and 
long,  commencing  1 
inch  from  anus  ; deep 
and  extensive  ulcera- 
tion 

Several  large  external 
growths  and  three 
fistulous  sinuses. 

232 


STRICTURE  OE  THE  RECTUM 


No. 

Age. 

Sex. 

Constitutional 
syphilis  or  not. 

Stricture  and  ulceration, 
where  found. 

Complications  and 
observations. 

32 

31 

F. 

None 

Stricture  1|  inch;  much 
soft  ulceration 

Outward  parts  normal ; 
died ; gradual  ex- 
haustion. 

33 

50 

F. 

None 

Stricture  2 inches  up ; 
ulceration  above  and 
below 

No  complication. 

34 

37 

F. 

Cons.  syph. 

Stricture  % inch  from 
anus ; ulceration  high 
up 

Rupia;  fistula  in  ano; 
10  years  syphilis. 

35 

22 

F. 

None 

Stricture  2%  inches  up ; 
ulceration  above  and 
below 

Haemorrhoids. 

36 

13 

F. 

None 

Stricture  about  2 inches 
up ; little  ulceration 

Fissure  and  polypus. 

37 

28 

F. 

Cons.  syph. 

Stricture  2 inches  up; 
ulceration  above  and 
below 

No  complication;  10 
years  syphilis 

38 

25 

F. 

Ditto 

Stricture  1^  inches  up; 
ulceration  above  and 
below 

Fistula  through  labia 
and  into  anus ; 

growths. 

39 

33 

F. 

Doubtful ; no 
history  or 
symptoms 

Stricture  just  within 
reach ; ulceration  be- 
low 

Fistula  in  ano;  recto- 
vaginal fistula. 

40 

37 

F. 

Cons.  syph. 

Stricture  2 inches;  se- 
vere ulceration 

Fistula ; growths ; co- 
lotomy ; success. 

41 

27 

F. 

None 

Stricture  annular,  3 
inches  up ; severe  ul- 
ceration 

None ; cured  by  incision 
and  dilatation. 

42 

37 

F. 

Cons.  syph. 

Stricture  1|  inch  up; 
very  severe  ulceration 

Huge  outside  growths 
and  labial  fistula ; co- 
lotomy ; success. 

43 

27 

F. 

None 

Stricture  1 inch  up ; 
superficial  ulceration 

None ; cured  by  division 
and  dilatation. 

44 

30 

F. 

Cons.  syph. 

Stricture  2 inches  up ; 
ulceration  slight 

Recto-vaginal  fistula. 

45 

26 

F. 

None 

Stricture  If  inch  up ; 
severe, deep  ulceration 

Club  - shaped  growths 
outside  around  anus. 

46 

25 

F. 

Cons.  syph. 

Stricture  2 inches  up  ; 
ulceration  above  and 
below 

Fistula  in  ano. 

47 

35 

F. 

None 

Ulceration,  so  that  the 
os  and  cervix  uteri 
came  through  into 
the  rectum 

The  uterus  could  not  he 
returned ; she  men- 
struated into  rectum . 

48 

22 

F. 

Cons.  syph. 

Impermeable  stricture 
2 inches  up 

Constipation  3 weeks; 
colotomy ; success. 

49 

30 

F. 

Very  doubtful 

Stricture  2 inches  up ; 
not  much  ulceration 

None. 

50 

30 

F. 

Cons.  syph. 

Stricture  high  up ; ul- 
ceration severe 

Fistula  and  outside 
growths ; syphilis  5 
or  6 years. 

51 

25 

F. 

None. 

Stricture  2 inches;  ul- 
ceration slight 

Internal  fistula ; bur- 
rowing up  under 
stricture. 

ULCERATION  OP  THE  RECTUM 


233 


No. 

Age. 

Sex. 

Constitutional 
syphilis  or  not. 

Stricture  and  ulceration, 
where  found. 

Complications  and 
observations. 

52 

24 

F. 

Cons.  syph. 

Stricture  1 inch  up ; 
ulceration  severe 

Fistula ; growths ; ru- 
pial  rash. 

53 

28 

F. 

Ditto 

Stricture  2 inches  up  ; 
ulceration  only  above 
the  stricture 

Fistula ; very  recent 
stricture,  only  noticed 

6 months ; indurated 
sores  on  nyrnpha. 

54 

18 

F. 

Ditto 

Stricture  1|  inch;  no 
ulceration  at  all 

Verrucse;  labial  abscess. 

55 

25 

F. 

Ditto 

Stricture  inches  up  ; 

ulceration  severe 
above  and  below 

Haemorrhoids  and  fis- 
tula. 

56 

32 

F. 

Ditto 

Stricture  very  high,  only 
just  to  be  felt ; ul- 
ceration very  deep 

Fistula,  several  sinuses; 
colotomy  ; success. 

57 

22 

F. 

None 

Stricture  1|  inch  up; 
very  little  ulceration 

Disease  of  uterus 

58 

29 

F. 

None 

Stricture  3 inches  up ; 
ulceration  below  slight 

Fistula  in  ano  and 
fissure. 

59 

62 

F. 

None 

Stricture  1 inch  up; 
ulceration  above 

Four  fistulae  around 
anus,  one  perforating 
the  vaginal  wall. 

60 

47 

F. 

None 

Stricture  only  just  to  be 
felt ; ulceration  below 

Fistula  in  ano;  com- 
plete opening  below 
stricture. 

61 

50 

M. 

Cons.  syph. 

Stricture  3 inches  from 
anus ; much  ulcera- 
tion 

N umerous  fistulae ; great 
debility ; went  home 
and  died. 

62 

53 

M. 

Ditto 

Stricture  2 inches  above 
anus;  ulceration  from 
anus 

Several  hard  ulcerated 
growths ; very  badly 
syphilised,  5 years. 

63 

40 

M. 

None 

Stricture  3 inches ; 
ulceration  all  around 
rectum 

Bad  fistula, faecal  matter 
passing  through ; co- 
lotomy (alive  8 years 
after  operation). 

64 

34 

M. 

Cons.  syph. 

Stricture  1 inch;  ulcera- 
tion above  and  below 

Ulceration  down  to 
anus  ; fistula  in  ano. 

65 

26 

M. 

Ditto 

Stricture  1^  inch ; ulcer- 
ation severe  above 

Stricture  almost  impass- 
able ; colotomy  (alive 
now,  10  years). 

66 

38 

M. 

Ditto 

Stricture  2 inches ; ul- 
ceration severe 

Two  fistulous  sinuses  ; 
bad  condition. 

67 

29 

M. 

None 

Stricture  1 inch,  annu- 
lar ; slight  ulceration 

Phthisical ; anus  lost 
all  power. 

68 

19 

M. 

Cons.  syph. 

No  stricture;  all  slough- 
ed away 

Phthisis  combined  with 
syphilis  had  played 
havoc  with  him. 

69 

80 

M. 

None 

Stricture  extending 

from  anus  3 inches 
up,  very  hard 

Thought  to  be  cancer, 
but  dilatation  and 
small  doses  of  mer- 
cury cured  him. 

70 

50 

M. 

None 

Annular  stricture  2 
inches  up ; not  severe 
ulceration 

Anus  normal ; speedy 
cure  by  division  and 
dilatation. 

284 


STRICTURE  OF  THE  RECTUM 


We  may  briefly  call  attention  to  some  important 
points  in  the  above  table.  In  70  patients,  60  were 
females  and  10  males,  a large  predominance  of  the 
former,  bub  not  so  great  as  has  been  given  by  some 
authors.  Now,  you  will  find  on  examining  the  table 
that  35  had  suffered  from  undeniable  constitutional 
syphilis,  while  5 had  some  symptoms,  but  not  decisive, 
of  ever  having  had  the  disease,  so  I think  this  number 
should  be  deducted  from  the  whole  number  70,  before 
we  consider  the  statistics  of  the  rest,  viz.  65,  and  we 
find  35  were  most  undoubtedly  syphilitic,  and  30  as 
undoubtedly  never  had  contracted  syphilis,  and  many 
never  any  venereal  disease. 

The  males,  though  small  in  number,  are  worthy  of 
a moment's  consideration;  of  the  10  males,  6 had 
suffered  from  some  form  of  syphilis ; but  4 had  not, 
and  there  was  great  probability  that  they  had  not 
been  affected  by  any  venereal  disease ; they  denied  any 
venereal  taint,  and  I think  from  the  way  they  spoke, 
and  the  desire  they  had  not  to  deceive  me  (as  I made 
it  a matter  of  great  importance  to  them  as  regards 
treatment  that  they  should  tell  me  the  truth),  I felt 
bound  to  believe  them. 

Ten  of  my  cases  were  subjected  to  colotomy  in  the 
lumbar  region,  and  for  the  most  part  did  well,  and 
I believe  several  (5  or  6)  are  now  alive.  Two  of  the 
women  have  married  since  the  operation.  In  one 
female  I attempted  to  open  the  ascending  colon,  and 
after  a most  careful  search  I failed  to  find  it,  but  in 
mistake  opened  the  duodenum,  as  it  embraces  the  head 
of  the  pancreas.  I like  to  mention  this  case  to  show 
how  in  difficult  cases  a practised  colotomist  may  go 
astray.  This  patient  had  a very  enlarged  liver,  and 


ULCERATION  OE  THE  RECTUM 


235 


was  in  the  habit  of  tight  lacing,  so  the  liver,  being 
pressed  downwards,  carried  the  ascending  and  trans- 
verse colon  diagonally  to  the  left  side,  and  the  post 
mortem  examination  showed  that  it  was  next  to  im- 
possible to  reach  the  ascending  colon  from  my  incision. 
I must  observe,  that  the  duodenum  when  brought  up 
from  a depth  is  very  like  the  colon.  Four  hours  after 
the  operation  I knew  what  I had  done,  as  a large  and 
constant  flow  of  bile  took  place  from  the  wound,  she 
vomited  frequently,  could  take  no  nourishment,  and 
died  on  the  third  day. 

Before  and  since  that  operation  I have  opened  the 
ascending  colon  and  found  no  particular  difficulty,  but 
there  is  no  doubt  that  the  ascending  colon  is  more 
liable  to  be  displaced  than  the  descending.  I do  not 
in  any  way  wish  to  extenuate  my  error  in  the  case ; 
at  the  time  I grieved  seriously  over  it,  and  I 
have  never  forgotten  it.  I always  think  I ought  to 
have  made  a more  careful  examination,  and  to  have 
found  that  the  liver  was  enlarged,  and  came  as  low 
down  as  the  crest  of  the  ilium,  and  so  was  almost 
certain  to  push  the  ascending  colon  out  of  place ; 
further,  I now  think  I ought  by  manipulation  and  per- 
cussion to  have  found  that  the  ascending  and  transverse 
colon  was  out  of  position.  However,  we  may  learn 
more  from  our  errors,  if  we  take  them  to  heart  and 
study  them,  than  from  all  our  successful  cases.  In 
forty-seven  operations  the  case  I have  related  is  the 
only  one  in  which  I made  any  mistake  or  failed  to  find 
the  colon. 

Of  the  30  patients  who  had  never  been  syphilised, 
it  was  possible  that  many  more,  but  highly  probable 
that  13,  had  never  had  any  venereal  affection  whatever, 


236 


STRICTURE  OF  THE  RECTUM 


Inoculation  in  all  these  cases  proved  abortive,  either 
there  being  no  result,  or  only  a small  evanescent  pimple 
appearing. 

The  cases  here  mentioned  are  No.  5,  observed  for 
8 years,  died  of  exhaustion ; would  not  submit  to 
colotomy. 

No.  7.  Colotomy  performed  with  success,  all  ulcers 
healing ; this  patient  has  now  been  seven  years  in  good 
health. 

No.  16.  Had  large  fibroid  polypus  with  stricture 
and  ulceration ; removal  of  polypus  and  dilatation 
with  incision  effected  a cure. 

No.  18.  Division  effected  a permanent  cure. 

No.  25.  Colotomy  effected  cure,  patient  watched  for 
years  and  found  well;  eventually,  all  the  strictures 
being  cured,  the  wound  in  the  loin  was  closed. 

No.  29.  Division  of  fistula  and  dilatation  of  stricture 
effected  a cure. 

No.  36.  Fissure  and  polypus,  with  ulceration  and 
stricture;  operation,  subsequent  dilatation;  cured,  some 
months  after  found  well. 

No.  43.  Stricture  and  ulceration  cured  by  incision 
and  dilatation. 

No.  57.  Disease  of  uterus,  enlargement  of  fundus, 
retro-version,  Hodge,  dilatation,  cure. 

No.  59.  Stricture  and  fistula,  ulceration,  careful 
division  of  fistula  and  stricture,  cure  permanent. 

No.  67.  Male,  annular  stricture  and  ulceration, 
phthisis,  relief. 

No.  69.  Stricture  very  long  and  hard,  gradual  dila- 
tation of  stricture,  cure,  and  no  relapse. 

No.  70.  Annular  stricture  high  up,  incision  and 
dilatation  of  stricture,  cure. 


ULCERATION  OF  THE  RECTUM 


237 


With  regard  to  inoculation,  I performed  it  on  many 
patients  in  whom  severe  constitutional  symptoms  of 
syphilis  with  outside  growths  existed,  and  never  got  a 
true  chancroid  as  the  result ; I noticed  many  small 
pimples  and  sores  which  healed  in  a few  days,  but 
never  a typical  soft  chancre,  I therefore  certainly  did 
not  inoculate  from  a soft  sore. 

I know  many  of  these  patients  died  after  years  of 
treatment,  numbers  of  them  being  admitted  and  re- 
admitted into  the  hospital.  They  die  either  of  some 
intervening  acute  disease,  obstruction  in  the  bowel,  or 
gradually  undermined  and  broken-down  health,  the 
workhouse  infirmary  often  sees  their  end,  which  may 
be  very  rapid.  In  sixteen  cases  I performed  Yerneuil’s 
operation  of  linear  rectotomy,  but  always  with  the 
knife,  never  with  the  ecraseur  or  galvanic  cautery  as 
he  has  recommended.  One  thing  I have  learned  in 
my  long  practice — not  to  fear  any  haemorrhage  from 
the  rectum. 

This  is  the  essence  of  Prof.  Verneuirs  operation  : — 
the  whole  stricture  must  be  divided  from  its  upper 
edge  down  to  the  coccyx,  and  through  its  entire 
depth.  Thus  a deep  drain  is  made,  from  which  all 
discharges  freely  flow,  and  as  it  heals  up,  the  ulcer- 
ation ceases,  and  the  stricture  is  sometimes  cured. 
The  patient  being  in  lithotomy  position,  what  I do 
is  simply  to  pass  my  finger  through  the  stricture; 
I then  introduce  a long  straight  knife  along  my 
finger,  and  when  the  point  is  fully  above  the  stric- 
ture I cut  firmly  down  right  through  it  in  its  whole 
depth,  even  to  the  sacrum  if  necessary,  and  bring 
the  knife  out  at  the  tip  of  the  coccyx.  If  you  keep 
the  median  line  the  bleeding  is  but  trifling,  and  the 


238 


STRICTURE  OF  THE  RECTUM 


whole  of  the  diseased  structure  will  have  been  cut 
through. 

So  rapidly  beneficial  is  this  operation,  tbat  in  forty- 
eight  hours  I have  often  seen  night  sweats  arrested, 
and  a patient  who  seemed  about  to  die  rally  and  eat 
and  drink,  and  get  well  from  that  moment ; morbific 
discharges  instead  of  being  absorbed,  run  out,  and  the 
patient  is  not  poisoned.  The  wound  should  be  well 
syringed,  and  the  parts  kept  perfectly  clean.  I always 
use  dry  absorbent  cotton  wadding  as  the  dressing,  and 
I only  want  my  patient  washed  at  most  twice  in  the 
day ; too  frequent  use  of  any  fluid,  carbolised  or  not, 
soddens  and  weakens  the  granulations ; if  you  want 
these  cases  to  do  well,  dry  dressings  are  those  I advise 
you  to  employ. 

Many  of  these  patients  have  done  well,  and  I have 
had  permanent  cures,  but  others  have  failed,  and  I 
have  seen  a return  after  even  three  or  four  years. 
In  the  after-treatment  I often  place  a tube  in  the 
wound,  keeping  it  in  at  night,  which  tends  to  prevent 
contraction. 

More  of  the  seventy  cases  would  have  been  subjected 
to  colotomy,  but  often  it  is  difficult  to  get  the  patient 
to  consent,  as  I think  it  proper  to  put  fairly  before  tbe 
sufferer  the  disadvantages  as  well  as  advantages  of  the 
operation. 

Many  cases  were  treated  by  dilatation,  assisted,  in 
some  instances,  by  small  incisions ; great  care  and  pains 
are  required  in  the  treatment  by  dilatation,  but  it  may 
be  satisfactory,  and  I will  relate  some  cases  in  which  it 
was  eminently  so.  Stricture  of  the  rectum,  however, 
is  a disease  infinitely  more  uncertain,  more  prone  to 
relapse,  and  more  difficult  to  treat  than  stricture  of  the 


ULCERATION  OP  THE  RECTUM 


239 


urethra.  In  some  few  cases,  immense  good  resulted 
from  the  administration  of  iodide  of  potassium  and 
mercury ; but,  on  the  other  hand,  often  when  it  was 
expected  to  benefit,  no  curative  result  followed.  On 
the  whole,  therefore,  I place  no  faith  in  specifics. 

I think  it  is  very  advantageous  to  compare  the 
results  of  our  hospital  with  our  private  practice,  so 
different  are  the  patients  in  many  respects — their  habits, 
the  food  they  take,  the  houses  they  inhabit,  their 
cleanliness,  sobriety,  the  comparatively  early  stage  of 
the  malady  at  which  they  seek  good  advice, — that  one 
often  finds  the  success  in  private  practice  so  much 
greater  as  to  be  really  astonishing.  I shall  proceed  as 
shortly  as  I can,  consistent  with  clearness,  to  give  the 
heads  of  cases  treated  in  private  by  me  during  the  past 
few  years.  Time  prevents  my  pushing  my  researches 
further  back  than  the  beginning  of  1876. 

Case  1. — Female,  married,  37.  No  children,  no  miscarriages ; stric- 
ture about  three  inches  up  the  rectum ; ulceration  both  below  and 
above  it ; no  history  of  syphilis  at  all ; never  had  any  sores  nor  dis- 
charge more  than  a little  whites ; has  no  pain  except  such  as  arises  from 
straining  and  frequent  desire  to  visit  the  closet.  The  husband,  per- 
fectly willing  to  clear  up  the  question,  examined — Never  had  syphilis, 
but  had  gonorrhoea,  but  not  since  his  marriage  eight  years  ago ; never 
had  any  soft  sore  or  enlarged  glands  in  groin.  No  scars  on  penis 
or  in  groin.  The  disease  his  wife  suffered  from  was  complained 
of  about  five  years  ago;  has  had  advice  and  bougies  passed.  I 
thought  it  advisable  to  divide  the  stricture  in  several  places,  and 
keep  in  a tube  at  night.  Various  plans  of  treatment  were  employed 
with  the  result  of  a cure  in  nine  months ; good  reason  to  believe  she 
continues  well. 

Case  2. — Female,  married,  27.  Had  children  and  miscarriages;  at 
her  last  two  confinements  children  alive  and  appear  well.  Husband  con- 
tracted syphilis  since  his  marriage,  secondaries  followed,  and  his  wife, 
then  enceinte,  became  syphilitic ; child  died  a few  weeks  after  birth ; it 
seemed  healthy  but  feeble.  She  was  treated  then  by  her  medical  man 
for  secondary  syphilis.  Ulceration  and  stricture  two  inches  from  anus  ; 


240 


STRICTURE  OF  THE  RECTUM 


no  symptoms  of  syphilis  now.  She  suffers  much  from  the  bowel. 
Careful  dilatation  and  treatment  of  ulceration  made  her  quite  com- 
fortable, but  I feel  sure  to  this  day  she  is  not  quite  well.  Seen  with 
Dr  Smith,  of  Blackfriars. 

Case  3. — Female,  married,  30.  Constitutional  syphilis,  acquired 
from  the  husband.  No  miscarriages,  but  two  children  had  syphilis ; 
were  treated  and  are  now  living.  Examination. — Almost  impassable 
stricture,  obstruction  so  great  that  I performed  colotomy,  the  late  Mr 
T.  Carr  Jackson  assisting  me ; result  good,  but  continued  discharge 
from  the  rectum  and  the  stricture  very  tight.  I have  been  seeing  this 
patient  occasionally  for  the  last  four  years.  The  husband,  a dissipated 
man,  has  had  all  kinds  of  venereal  disorders. 

Case  4. — Female,  married,  48.  No  constitutional  syphilis,  and  has 
never  had  any  symptoms.  Husband  healthy,  and  says  never  had  any 
venereal  affection  of  any  kind;  married  very  young,  his  wife  being  not 
nineteen.  Eldest  child  eighteen,  and  all  family  healthy.  Examination. 
— Stricture  and  some  ulceration  two  and  a half  inches  from  anus ; 
good  deal  of  pain  and  straining.  Slight  division  and  careful  dilatation 
effected  a cure  in  five  months.  I am  informed  that  this  patient  has 
continued  well  since. 

Case  5. — Female,  married,  38.  No  symptoms  of  constitutional 
syphilis ; has  healthy  children ; very  painful  annular  stricture  near 
anus ; some  swollen  flaps  of  skin  extrude  ; ulceration  extending  for  an 
inch  and  a half  upwards.  The  husband  confesses  to  syphilis,  but 
considered  himself  as  quite  well  years  before  his  marriage;  has  no 
symptoms  now;  division  of  the  stricture;  blue  ointment  with  opium 
to  ulceration  and  careful  dilatation  cured  her  in  about  two  years.  I 
have  not  heard  of  any  relapse. 

Case  6. — Female,  married,  37.  Stricture  and  ulceration  rather  severe  ; 
stricture  one  and  a half  inches  from  anus  ; suffers  much  ; has  dimness 
of  vision  which  I found  to  be  caused  by  iritis ; has  syphilitic  rash ; 
rupial ; is  very  cachectic  and  feeble ; one  child  nine  years  old  quite 
healthy.  Her  husband  was  under  my  care  about  twelve  years  ago 
for  indurated  sore ; moderate  mercurial  treatment  for  six  months ; all 
symptoms  gone,  and  left  off  medicine.  Seen  again  after  nine  months 
with  secondary  rash,  rather  scaly,  and  sore  throat ; mercurial  treat- 
ment again,  hydr.  cum  cret.  at  bedtime,  and  blue  ointment  between  the 
toes  ; very  soon  well,  and  would  not  take  any  more  medicine.  Came  to 
me  four  years  after  to  consult  me  about  the  propriety  of  marrying.  On 
careful  examination  I could  find  no  evidence  of  syphilis,  so  thought 
he  was  justified  in  doing  what  he  liked.  He  soon  after  I saw  him 


ULCERATION  OF  THE  RECTUM. 


241 


married,  and  the  only  child,  born  fifteen  months  after  marriage,  was 
healthy,  and  has  continued  so.  To  return  to  the  wife,  three  years 
after  her  marriage  she  had  a rash  and  sore  throat.  She  was  treated 
by  her  medical  attendant  with  iodide  of  potassium,  and  she  quickly 
recovered;  the  husband  during  this  time  had  flying  attacks  of 
syphilis,  for  which  he  saw  me  two  or  three  times,  but  took  by  his  own 
prescription  iodide  of  potassium  and  sarsaparilla.  This  went  on  until 
the  wife  having  severe  bowel  symptoms  was  sent  to  me.  The  treatment 
consisted  of  mercury  and  iron ; the  stricture  was  a little  dilated,  and 
she  was  sent  to  the  sea- side;  great  improvement  took  place  in  general 
health,  the  iritis  got  rapidly  well,  and  the  stricture  was  much  modified 
by  gentle  dilatation  ; the  ulceration  also  healed  in  great  measure,  so 
that  she  suffered  but  little,  and  the  bowels  acted  only  about  twice  in 
the  day.  The  husband  denied  any  fresh  infection  since  his  marriage ; 
slight  crops  of  secondary  character  were  frequent,  and  he  on  one  occa- 
sion had  an  indurated  crack  at  the  orifice  of  the  urethra.  The  wife 
eventually  was  quite  cured.  I have  related  the  above  somewhat  in 
detail,  as  one  has  rarely  so  good  an  opportunity  of  watching  such  a 
case  so  long. 

Case  7. — Female  36,  married  many  years.  Sent  me  by  Dr  Playfair. 
Husband  says  never  had  syphilis  ; no  symptoms  in  his  wife.  Stricture 
two  and  a half  inches  from  anus : slight  ulceration ; a very  feeble 
woman ; never  any  children ; tendency  to  lung  affection.  Phthisis  in 
family;  has  from  soon  after  marriage  suffered  from  inflammation  of 
the  uterus,  and  has  now  a fibroid  in  its  posterior  wall.  Has  a very 
spasmodically  contracted  sphincter,  and  the  stricture  is  long,  so  that 
one  cannot  feel  the  extent  of  it ; despite  all  treatment  this  case  went  on 
to  total  obstruction,  and  colotomy  was  performed.  The  case  did  well ; 
duration  of  stricture  at  least  ten  years. 

Case  8. — Female,  married,  set.  45,  no  children.  Ho  history  at  any 
time  of  syphilis.  Sent  me  by  Mr  Burton  of  Blackheath.  Stricture 
and  slight  ulceration  three  inches  up  from  anus;  no  symptom  of 
present  or  past  syphilis  in  patient  or  husband;  great  relief  in  six 
months ; treatment  by  dilatation  and  mercurial  ointment.  Saw  this 
patient  lately  and  she  remains  well. 

Case  9. — Female,  set.  50 ; this  lady  came  from  Philadelphia  to  be 
under  my  care.  History  very  doubtful,  but  has  had  many  and  healthy 
children,  and  several  difficult  labours ; no  deaths ; no  miscarriages ; 
children  nearly  grown  up.  Yery  bad  stricture  and  ulceration;  linear 
rectotomy  in  the  median  line;  tubes  kept  in  for  weeks ; eventually  a 
very  perfect  cure ; stayed  six  months  in  England,  and  went  away  with- 
out any  tendency  to  contraction.  I heard  from  this  patient  a few 
years  ago  ; after  she  left  my  care,  she  continued  perfectly  well. 

16 


242 


STRICTURE  OF  THE  RECTUM 


Case  10. — Female,  married,  ait.  37.  No  family,  the  wife  of  a medical 
man.  Stricture  near  anus,  ulceration,  swollen  tabs  of  skin,  ichorous 
discharge.  The  husband  had  a bard  sore  and  secondary  symptoms  not 
long  before  marriage,  and  knew  he  had  affected  his  wife,  whom  he 
treated  from  time  to  time.  Now,  after  an  interval  of  about  seven 
years,  the  first  symptom  appeared  in  his  wife,  the  husband  at  the 
same  time  showing  mucous  sores  on  the  lip  and  anus.  Treated  for  a 
long  time  by  specifics  and  local  treatment,  including  division  of  the 
stricture,  but  with  only  great  relief,  maintained  by  constantly  wearing 
a tube ; no  permanent  cure  I fear  will  be  effected. 

Case  11. — Female,  married,  set.  29.  Severe  ulceration  ; stricture  two 
inches  up  the  rectum ; recto -vaginal  fistula.  Husband,  a dissipated 
man,  confesses  to  have  had  syphilis  and  gonorrhoea  many  times.  The 
wife  had  tertiary  sores  on  legs;  mucous  papules  ; nodes  on  head;  very 
cachectic  and  feeble ; small  doses  of  mercury  were  given  twice  in  the 
day,  with  iodide  of  potassium  and  arsenic  with  decoction  of  cinchona ; 
good  diet  and  fresh  air  soon  restored  her  health,  and  attention  was 
bestowed  on  the  stricture ; it  was  divided  in  several  places  very  lightly 
and  a tube  worn,  but  the  tenderness  defeated  all  the  treatment,  she 
could  not  retain  anything.  Suppositories  or  sedative  injections  were 
at  once  returned  and  pain  was  increased.  Her  health  again  broke 
down,  and  as  a last  resource  colotomy  was  performed,  but  she  lived 
only  three  months  ; relieved  from  pain,  but  never  rallied. 

Case  12. — Female,  married,  set.  60  (widow).  Stricture  a little  way 
up  the  bowel,  one  and  a half  inches ; slight  ulceration.  Has  many 
children  grown-up  healthy;  only  for  a few  years  suffered  discharge; 
frequent  going  to  stool  and  general  decline  of  health.  Sent  me  by  Mr 
Sloman,  of  Farnham.  Division  and  dilatation  of  stricture ; mercurial 
and  opiate  treatment  of  the  ulceration;  wearing  a tube  at  night 
effected  a great  improvement,  in  fact  I think  there  is  every  reason  to 
hope  for  a cure.  I have  since  heard  of  this  lady  doing  well. 

Case  13. — Female,  unmarried,  set.  55.  Sent  to  me  by  the  late  Dr  Lock- 
hart Clarke.  For  many  years  has  suffered  from  difficulty  in  the  bowels. 
Examination. — Long  and  tight  stricture  two  inches  from  anus ; very 
little  ulceration,  but  considerable  roughness  nearer  the  anus,  evidently 
the  scars  of  old  ulceration ; the  index  finger  could  be  passed  through 
the  stricture  after  some  pressure.  The  history  of  the  past  showed  that 
she  had  suffered  much  in  the  rectum,  pain,  bleeding,  discharge  of 
mucus  and  constipation,  alternating  with  diarrhoea.  Had  consulted 
many  physicians,  and  taken  enormous  quantities  of  medicine,  laxa- 
tive and  tonic ; she  had  taken  great  care  of  herself,  lying  up  much. 
Extreme  caution  in  diet,  liviug  almost  solely  on  fish,  vegetables,  and 


ULCERATION  OF  THE  RECTUM 


243 


fruit.  She  says,  on  the  whole,  constitutionally  she  is  better,  but 
increasing  difficulty  in  obtaining  relief  brought  her  to  me.  The  case  I 
considered  one  very  amenable  to  treatment  by  dilatation  and  keeping 
in  the  tube  at  night.  This  I adopted,  and  in  three  months  she  was 
better  than  she  had  been  for  many  years.  This  ulceration  and  stric- 
ture, I have  no  doubt  from  the  history,  arose  from  inflamed,  and  per- 
haps suppurating,  haemorrhoids,  the  submucous  tissue  got  affected,  and 
ulceration  and  stricture  resulted.  There  was  no  appearance  of  any 
tuberculous  tendency,  and  certainly  no  syphilis,  acquired  or  hereditary. 
I cannot  see  why  in  many  cases  a similar  condition  may  fiot  result 
from  constipation  and  inflammation. 

Case  14. — Female,  married,  set.  34,  attended  with  Mr  Seymour  Haden. 
Stricture  for  long  time ; seen  by  Mr  Haden  one  month  ago,  when  the 
obstruction  was  almost  total,  and  she  had  constant  vomiting.  Mr 
Haden  got  a tube  through  and  relieved  the  obstruction,  Ho  history  of 
syphilis  or  struma  in  the  patient  or  husband ; the  question  of  syphilis 
in  my  own  mind  was  quite  settled  in  the  negative.  I attended  this 
patient  for  some  time  and  she  much  improved.  Her  husband  was  a 
chemist,  and  with  a little  teaching  became  quite  skilful  in  passing  the 
bougie.  I lost  sight  of  the  patient,  and  do  not  know  the  ultimate 
result.  My  opinion  was  that  the  cause  of  the  stricture  was  very 
severe  labours,  and  long  pressure  of  the  child’s  head.  It  is  not  un- 
common for  women  to  connect  their  bowel  trouble  with  a bad  or 
instrumental  labour.  Although  I should  not  consider  this  a common 
cause  of  ulceration  and  stricture,  it  ought  not  to  be  left  out  of  our 
consideration. 

Case  15. — Female,  unmarried,  set.  27.  Seen  by  me  in  conjunction 
with  Mr  Aikin,  and  afterwards  with  Sir  James  Paget.  Had  been 
operated  upon  for  fistula,  and  ulceration  followed,  severe  in  character; 
got  better  and  worse.  Brighton  air  did  her  so  much  service  that  a 
happy  result  was  anticipated,  but,  however,  she  fell  back  again.  When 
I saw  her  with  Mr  Aikin  the  sphincters  were  quite  ulcerated  away ; 
with  great  difficulty  the  finger  could  be  got  through  a stricture  two 
inches  up  the  bowel.  The  history  led  me  to  conclude  that  the  disease 
was  tubercular;  I advised  immediate  colotomy.  I did  not  see  this 
patient  until  four  months  later,  when  she  was  much  worse ; abscesses 
had  formed  in  the  groin,  and  a communication  was  established  between 
the  vagina  and  rectum  ; her  condition  was  so  deplorable  that  an  opera- 
tion was  undertaken  only  as  a means  of  relief  by  turning  aside  the 
faeces.  With  the  sanction  of  Sir  James  Paget  and  Mr  Aikin  I per- 
formed colotomy.  After  the  operation  I pointed  out  that  the  ulcera- 
tion could  be  detected  from  the  aperture  in  loin  by  passing  the  finger 


244 


STRICTURE  OF  THE  RECTUM 


towards  the  rectum.  Her  history  from  this  period  was,  some  tempo- 
rary arrest  of  the  ulceration,  hut  this  did  not  last  long,  and  soon  it 
could  he  seen  on  the  howel  in  the  lumbar  opening.  Abscesses  formed 
in  all  directions,  and  burst  or  were  opened  in  several  places,  so  that  the 
interior  of  the  pelvis  could  be  seen.  She  died  just  three  months  after 
the  operation.  To  a certain  extent  relief  was  obtained,  but  not  so  much 
as  I think  would  have  resulted  had  colotomy  been  earlier  undertaken. 
The  ulceration  was  serpiginous  in  character. 

Case  16. — Female,  married,  set.  34,  no  children,  was  seen  by  me  in 
consultation  with  Dr  T.  B.  Crosby.  She  was  suffering,  and  had  been 
for  years,  from  tertiary  syphilis,  necrosis  in  the  tibiae  having  taken 
place;  had  not  undergone  anti- syphilitic  treatment  for  lengthened 
periods.  There  was  ulceration  and  tight  stricture  in  the  bowel ; the 
urethra  was  ulcerated  through  in  nearly  its  whole  length,  so  that  in- 
continence of  urine  resulted;  some  communication  had  taken  place 
between  the  bowel  and  the  bladder,  as  wind  freely  passed  on  her  making 
water  or  on  introducing  a catheter.  Treatment  was  undertaken  by 
passing  a bougie,  keeping  the  bladder  empty,  and  her  constitutional 
powers  were  much  improved  by  small  doses  of  mercury  and  tonics. 
Result  of  treatment  nugatory  as  regards  the  incontinence  of  urine. 

Case  17. — Female,  married,  set.  47,  no  children.  Seen  with  Mr 
Theophilus  Taylor.  Syphilis  undoubted,  tertiary  scars  being  present; 
ulceration  of  rectum  and  stricture ; very  much  discharge ; great  pain, 
straining,  and  constant  desire  to  go  to  stool ; constitution  very  much 
undermined.  The  stricture  was  so  tight  that  division  was  made  in 
dorsal  median  line,  and  bougies  soon  after  introduced.  Tonics  (iron 
and  mercury  in  very  small  doses)  were  administered ; after  long  treat- 
ment great  improvement  took  place.  The  wound  healed  and  the 
ulceration  was  very  slight,  so  that  the  discharge  became  almost  nil , 
and  was  mucous  rather  than  purulent.  She  was  instructed  to  pass  the 
bougie  (very  short  one)  herself ; she  could  safely  do  this,  as  the  stric- 
ture was  not  very  high  up.  When  last  seen  was  wonderfully  improved, 
but  had  incontinence  of  fa3ces  if  at  all  fluid.  Still,  the  comfort  she  had 
derived  from  treatment  was  most  marked  and  satisfactory  to  her  as  well 
as  to  her  medical  attendants. 

Case  18. — Female,  married,  set.  42.  Three  children  very  healthy. 
Sent  me  by  Dr  Herbert  Davies.  Suffered  for  a long  time  with  consti- 
pation and  straining  at  stool ; no  evacuation  obtained  without  medicine 
or  enemata ; rather  thin,  but  not  unhealthy  looking ; no  miscarriages ; 
no  history  or  appearance  of  syphilis.  Examination. — Found  tight, 
annular  stricture  one  and  a half  inches  from  anus ; ulceration  below 
the  stricture  as  well  as  slightly  above;  some  swollen  outside  skin,  not 


ULCERATION  OF  THE  RECTUM 


245 


discharging.  The  stricture  proved  very  dilatable,  so  the  use  of  the 
bougie  enlarged  it  much  in  about  three  weeks,  and  she  was  then  more 
comfortable  than  she  had  been  for  years.  The  ulceration  also  got 
better  by  the  use  of  a bismuth,  morphia,  and  pitch  ointment.  In  fact, 
so  much  better  was  this  patient  at  the  end  of  two  months  that  she  has 
not  visited  me  since. 

Case  19. — Female,  widow,  set.  59.  Sent  me  by  Mr  Pinching,  of 
Gravesend.  Long  troubled  with  her  bowels ; never  passes  formed 
motions,  always  in  small  broken  pieces  with  blood  and  slime  on  them  ; 
has  been  getting  thinner,  but  says  her  health  is  fair,  and  if  she  was 
comfortable  in  her  bowels  would  be  quite  well.  Examination. — Stric- 
ture tight,  i.  e.  could  only  get  forefinger  through,  and  this  caused  much 
pain ; the  edge  of  the  stricture  was  ulcerated ; many  years  ago  had 
been  operated  on  for  piles  at  a London  hospital ; she  was  in  poor  cir- 
cumstances then;  from  that  day  never  had  perfect  comfort  in  the  use 
of  her  bowels.  I slightly  divided  the  stricture  and  introduced  bougies 
gradually  increasing  in  size,  and  by  the  application  of  ointments  the 
ulceration  gradually  got  better,  so  that  she  could  sleep  all  night  with  a 
bougie  in  the  stricture.  In  three  months  she  was  quite  well;  no  trace 
of  stricture  could  be  felt,  but  corrugations  and  roughness,  showing  the 
healing  of  the  ulceration,  remained.  I saw  this  patient  more  than  a 
year  after  the  treatment,  and  she  continued  quite  well.  I have  no 
doubt  this  stricture  and  ulceration  was  the  result  of  the  operation  on 
the  piles. 

I have  seen  for  years  past  numerous  cases  of  ulcera- 
tion with  stricture  result  from  operations  upon  the 
rectum,  but  as  this  condition  usually  takes  place 
shortly  after  the  operation  and  is  manifestly  due  to 
it,  I have  not  given  any  histories  of  such  cases, 
although  they  frequently  take  a great  deal  of  time 
and  trouble  to  cure. 


Cases  in  private  practice  of  ulceration  and  stricture  in 

males 

Case  1. — Male,  set.  23.  In  the  army.  Had  a hard  sore  some  three 
years  back  and  was  treated.  After  a time  he  suffered  from  pain  on 
defalcation,  and  he  went  to  a surgeon,  who  said  he  had  syphilitic  sore 
and  must  be  operated  upon,  but  after  the  cutting  the  sore  became 


246 


STRICTURE  OF  THE  RECTUM 


worse,  and  he  came  to  me.  I found  the  sore  unhealed  and  inflamed, 
and  suspecting  more,  I with  difficulty  passed  my  finger  up  the  bowel, 
when  I found  that  above  the  sore,  which  had  been  divided,  there  was 
quite  an  inch  of  healthy  mucous  membrane  forming  a zone  around  the 
bowel,  then  some  more  ulceration  in  a zone  an  inch  in  width.  He  had 
no  other  sign  of  syphilis  but  a sore  throat.  Mercurial  ointment, 
arsenic,  and  iron,  with  cod-liver  oil,  as  he  was  weak  and  feeble,  soon 
made  an  improvement.  In  a fortnight  a bougie  could  be  passed,  and 
all  healed  in  about  eight  weeks. 

Case  2. — Male,  set.  40,  married ; had  never  had  syphilis,  but  told  a 
strange  story,  that  if  he  was  affected  it  arose  from  taking  a Turkish 
bath.  Yery  bad  ulceration  extended  two  inches  up.  Stricture  was 
tight,  and  he  had  much  pain,  and  got  no  relief  unless  he  took  large 
doses  of  purgatives.  Linear  rectotomy  and  twelve  months’  great  care 
nearly  cured  him.  I have  not  seen  him  during  the  year  and  a half 
which  has  elapsed  since  the  operation,  but  I have  heard  he  is  not  well. 

Case  3. — Male,  set.  29,  unmarried.  Had  syphilis,  and  was  treated  by 
Ricord,  of  Paris,  for  eighteen  months,  and  thought  himself  quite  well  ; 
had  lost  all  rash  and  all  symptoms  for  months,  and  then  discontinued 
all  his  medicines.  About  six  months  after  he  experienced  pain  and 
straining  on  defsecation.  As  he  was  coming  to  England  he  was  recom- 
mended to  me.  On  examination  I found  just  inside  the  anus  ulcera- 
tion, with  stricture,  very  painful  to  touch ; he  could  not  bear  the 
bougie.  The  use  of  an  ointment  composed  of  bismuth,  blue  ointment, 
and  opium,  soon  relieved  the  pain,  and  I was  enabled  to  dilate,  and  he 
kept  bougies  in.  This  patient  had  never  had  soft  sores  in  his  life,  nor 
even  gonorrhoea.  He  was  not  a strumous,  nor  in  any  way  a delicate 
man.  The  case  ended  favorably,  showing  the  desirability  of  early 
treatment. 

Case  4. — Male,  set.  28,  unmarried,  a native  of  India  studying  medi- 
cine in  this  country.  Had  suffered  from  dysentery  and  diarrhoea  fre- 
quently, but  not  severely,  in  his  own  country.  Has  been  in  England 
two  years  and  no  severe  attack,  in  fact,  much  better  here  than  abroad. 
About  one  month  ago  felt  pain  on  defsecation,  but  took  a little  laxative, 
and  found  himself  better,  but  still  straining  was  frequent,  with  mucous 
and  occasional  blood.  He  came  to  me ; he  was  a small,  thin,  agile  man 
of  more  than  average  intelligence.  Examination. — I found  three  inches 
from  anus  a stricture  through  which  only  a small  bougie  would  pass. 
Injections  of  opium  and  starch  in  very  small  quantities  relieved  the 
pain,  and  allowed  me  to  increase  the  size  of  the  bougie.  The  stricture 
proved  very  amenable,  and  he  was  soon  restored  to  perfect  comfort, 


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247 


and  his  health  improved.  I advised  the  continuance  of  the  short  small 
bougie. 

Case  5. — Male,  unmarried,  but  who  intended  to  be  married,  came  to 
me  about  an  uneasy  sensation  in  the  rectum,  frequent  diarrhoea,  and 
straining;  occasionally  mucus  passes  in  abundance;  was  treated  for 
syphilis  with  mercury  in  various  forms  by  one  of  our  best  surgeons  ; 
now  felt  himself  quite  well.  Examination. — Stricture  an  inch  and  a half 
from  anus,  above  the  stricture  ulceration.  The  stricture  was  hard  but 
the  ulceration  very  soft.  Had  no  other  venereal  affection  since  the 
sore.  Health  fair.  I found  it,  after  a time,  necessary  to  divide  the 
stricture  freely,  then  the  ulceration,  by  treatment — topical  chiefly — • 
rapidly  improved,  and  after  nine  months  he  was  fairly  well.  During 
my  treatment  I sent  him  to  Aix-la-Chapelle,  as  he  had  a return  of 
syphilitic  sore  throat  and  rash,  to  be  under  the  care  of  Dr  Brandish 
and  undergo  baths  and  mercurial  inunction.  He  came  back  without 
any  rash,  and  with  his  health  greatly  improved.  The  ulceration  had  then 
not  healed,  but  soon  after  he  got  quite  well,  and,  I think,  remains 
sound. 

Case  6. — Male,  single,  set.  47,  retired  captain  in  the  army  ; very  bad 
stricture  and  ulceration ; feeble  and  much  worn  and  emaciated ; says 
never  had  any  venereal  affection  whatever,  and  as  he  had  no  reason  for 
deceiving  me,  and  I could  find  no  trace  of  syphilis  anywhere,  I believed 
him.  For  some  years  he  had  this  affection,  and  when  in  the  army  in 
India  he  was  treated  with  bougies,  but  with  very  slight  advantage.  No 
history  of  phthisis  in  his  family.  Suffers  very  much.  A careful  course  of 
bougies,  keeping  them  in  when  he  could  bear  them,  a little  division  of  the 
strictures  (for  there  were  two)  in  several  places,  gradually  got  him  into 
comfort,  but  cure  seemed  hopeless.  He  returned  to  me  a few  months 
back,  and  finding  him  suffering  much  I proposed  colotomy,  to  which  he 
acceded.  The  operation  has  proved  a signal  success,  and  he  is  alive  now. 

Case  7. — Male,  single  ; said  to  have  had  only  soft  sore,  but  as  copious 
rash  followed,  I am  fain  to  believe,  although  the  diagnosis  was  made 
by  one  of  our  greatest  syphilographers,  that  an  error  was  fallen  into. 
Two  years  after  this  sore  he  suffered  pains  on  defaecation  and  came  to 
me.  On  examination  I found  stricture  and  ulceration  commencing  one 
inch  from  the  anus,  which  outside  appeared  normal.  The  stricture  was 
annular,  and  I divided  it  in  several  places  and  cautiously  dilated. 
Blackwash  lotion  benefited  the  ulceration,  but  iodoform  did  most 
good,  and  he  was  soon  well.  I advised  the  use  of  the  bougie  once  in 
the  week  for  some  months. 

Case  8. — Male,  set.  26,  lieutenant  in  the  army ; no  history  of  syphilis  or 
any  venereal  disease  whatever.  Ill  about  nine  months.  Saw  this  patient 


248 


STRICTURE  OF  THE  RECTUM 


with  Sir  James  Paget,  who  agreed  with  me  in  the  opinion  that  the  dis- 
ease was  strumous.  When  I first  saw  him  he  had  a very  tight  stricture 
close  to  the  anus.  This  I divided  and  dilated  only  to  find  another  stric- 
ture three  inches  higher  up,  and  plentiful  soft  ulceiation  between  the 
two  strictures.  Local  and  general  treatment  failed  to  do  good  ; a voyage 
of  some  months’  duration  had  a like  result.  When  he  returned  he  was 
seen  in  conjunction  with  me  by  Sir  William  Gull,  whose  opinion  coin- 
cided with  Sir  James  Paget’s  and  my  own.  He  is  still  being  watched, 
and  on  the  whole  is  better,  but  frequent  diarrhoea,  straining,  dis- 
charges of  blood  and  mucus  still  occur.  He  had  never  had  dysentery 
nor  habitual  diarrhoea. 

Case  9. — Male,  set.  37,  married.  History  of  soft  sores  under  prepuce 
and  buboes,  one  suppurating.  No  hardness  observed,  and  no  eruption 
or  symptoms  of  constitutional  syphilis  known.  Healthy  looking, 
strong  man.  An  interval  of  eight  months  elapsed  from  the  cure  of  his 
soft  sores  until  he  complained  of  passing  blood  and  mucus  with  pain 
per  anum.  This  went  on  for  some  time,  and  he  treated  it  as  piles, 
taking  laxative  medicines  and  using  lead  ointment.  Finding  no  benefit 
he  was  sent  from  the  country  to  me.  The  history  was  given  so  truth- 
fully that  I could  not  doubt  his  words.  He  had  no  symptoms  of 
syphilis,  but  he  showed  me  a wound  in  the  groin  where  one  bubo  was 
opened.  On  examining  the  rectum  I could  only  just  pass  my  finger 
through  the  stricture,  and  I found  ulceration  above  it,  but  no  trace  of 
any  below  ; he  had  small  external  piles,  but  no  ichorous  growths.  The 
treatment  was  slight  division  of  stricture,  wearing  a bougie  all  night 
smeared  with  bismuth  and  morphia  ointment,  to  keep  the  bowels  open 
by  the  liquorice  powder  (Pharm.  German),  to  avoid  all  alcohol  and 
meat,  and  to  live  on  farinaceous  food  and  plenty  of  milk.  Success 
soon  crowned  this  treatment,  and  in  three  months  was  quite  conval- 
escent. 


Case  10. — Male,  set.  46,  first  officer  in  American  line  of  steamships. 
Has  suffered  for  years  in  his  bowels,  terrible  constipation,  and  passed 
motions  with  blood ; much  pain  and  frequent  going  to  stool ; been 
treated  for  piles,  and  always  took  sulphur,  from  which  he  derives  con- 
siderable benefit.  Yery  strong,  healthy,  steady  man.  Never  had  any 
venereal  disease  at  all.  Steadfastly  held  to  this  statement.  Did  not 
mean  to  say  that  he  had  run  no  risk,  but  had  been  fortunate.  I could 
detect  no  sign  of  syphilis,  no  bubo  scars,  or  rash.  Examination  of 
rectum. — Tight  stricture  an  inch  and  a half  from  the  anus,  and  there 
was  ulceration  above  and  below  the  stricture.  I divided  the  stricture 
and  dilated,  keeping  in  a vulcanite  tube  for  several  days.  He  became 
so  much  better  that  at  the  end  of  three  weeks  he  again  went  to  sea, 


ULCERATION  OF  THE  RECTUM 


249 


using  at  night  a small  tube,  which  he  could  wear  with  comfort  and  no 
danger.  I saw  this  patient  many  times,  and  found  him  always  better, 
but  a slight  discharge  of  mucus  still  continued,  but  as  his  constipation 
was  removed  and  he  suffered  no  pain  he  became  quite  satisfied  with  the 
result.  The  only  thing  that  radically  benefited  his  constipation  after 
the  operation  and  dilatation  was  a dinner  pill,  which  he  took  every 
other  day,  composed  of  extract  nux  vomica,  ipecacuanha,  and  com- 
pound rhubarb  pill. 


From  a study  of  the  history  of  nineteen  females 
treated,  and  watched  afterwards  for  some  time,  it 
appears  that  seven  had  undoubted  signs  of  constitu- 
tional syphilis,  and  twelve  had  neither  the  symptoms 
nor  history  of  any  form  of  venereal  disease  ; thus  there 
was  much  less'  undeniable  syphilis  in  private  than  in 
hospital  practice.  In  the  non-syphilitic  patients,  the 
ulceration  was  mostly  tuberculous.  Two  patients 
ascribed  the  disease  of  the  bowel  to  many  difficult 
labours.  I cannot  see  why  iu juries  during  labour 
should  not  be  a source  of  ulceration  ending  in  a con- 
striction ; in  fact  I wonder  we  do  not  oftener  meet  with 
instances  in  which  this  cause  alone  can  be  assigned. 
One  case  resulted  from  an  operation  performed  upon 
the  rectum  long  since. 

In  most  cases,  having  the  husband  before  us  to 
interrogate  and  examine,  we  are  enabled  to  compare 
his  condition  with  that  of  his  wife.  I am  confident  that 
in  the  majority  the  evidence  of  the  husband  was  to  be 
depended  upon.  In  Case  3,  which  was  one  of  the 
worst  strictures  I ever  saw,  and  in  which  I was  com- 
pelled to  perform  colotomy,  the  husband  had  suffered 
from  all  kinds  of  venereal  infection.  Case  6 had  iritis 
and  well-marked  syphilitic  rash.  I knew  her  husband 
had  suffered  from  constitutional  syphilis,  as  I had 
treated  him.  The  poison  probably  was  quiescent  at 


250 


STRICTURE  OF  THE  RECTUM 


the  time  he  impregnated  his  wife,  as  the  child  was  born 
healthy  and  has  continued  so  up  to  nine  years  of  age. 
Twenty  months  after  the  child  was  born,  the  mother 
suffered  from  syphilis  for  the  first  time.  The  husband 
about  that  time  consulted  me  for  slight  flying  attacks 
of  secondary  symptoms,  and  he  said  there  had  been  a 
crack  at  the  entrance  to  the  urethra,  and  in.  my  opinion, 
that  crack  inoculated  his  wife ; she  was  not  under  my 
care,  and  no  search  was  made  for  any  sore,  and  it  was 
not  until  seven  years  after  she  had  become  syphilised 
that  she  came  to  me.  In  four  cases  lumbar  colotomy 
was  performed. 

A few  words  about  the  male  patients,  who  were  ten 
in  number : observe  in  private  practice  how  many 
more  men  in  proportion  to  women  than  in  hospital 
practice.  Three  had  decided  constitutional  syphilis. 
One  had  doubtful  symptoms.  One  had  suffered  from 
a soft  sore  under  the  prepuce,  accompanied  by  a sup- 
purating bubo,  and  the  remainder,  viz.  five  patients, 
had  no  syphilitic  or  venereal  taint.  Of  these,  repeated 
dysentery  was  probably  the  cause  in  one  if  not  two. 
Two  resulted  from  tuberculosis  (my  opinion  in  these 
cases  was  sustained  by  Sir  James  Paget).  One 
resulted  possibly  from  the  hard  life  of  a sailor ; bad 
feeding,  exposure  to  weather,  dysenteric  diarrhoea  at 
times,  but  usually  the  most  intractable  constipation, 
his  rectum  for  years  was  constantly  irritated  by 
contracting  upon  hard  and  dried  masses  of  fasces.  In 
such  a case  injury  to  the  mucous  membrane  could  not 
be  an  unexpected  event.  It  is  often  difficult  to  trace 
the  cause  in  a case  of  ulceration,  but  really  such  con- 
ditions as  I have  described  must  sometimes  be  either 
predisposing  or  exciting.  In  one  case  only  was  I 


ULCERATION  OF  THE  RECTUM 


251 


obliged  to  perform  lumbar  colotomy.  In  one  case 
also,  Verneuil’s  operation  was  done  ; the  success,  how- 
ever was  more  than  doubtful,  as  I have  heard  this 
patient  is  still  suffering.  I have  found,  speaking 
generally,  that  a fair  amount  of  relief  is  more  frequently 
attained  by  treatment  in  men  than  in  women.  Various 
reasons  will  suggest  themselves  to  my  readers,  as  con- 
ditions of  the  uterus,  ovaries,  vagina,  coitus,  &c.  Lastly, 
I would  observe  that  complete  cures  are  seldom,  if 
ever  obtained,  but  great  relief  is  not  uncommon,  and 
in  favorable  cases,  by  proper  attention,  the  patient’s 
life  may  scarcely  be  shortened  by  the  malady. 

On  summing  up  my  own  statistics  I can,  in  short, 
state  that  in  women  forty-two  out  of  seventy-nine  had 
suffered  or  were  suffering  from  undoubted  constitu- 
tional syphilis,  and  in  twenty  males,  half  were  in  the 
same  condition,  thus  out  of  the  total  number  of  ninety- 
nine  patients,  fifty- two  (or  more  than  half)  were 
syphilitic.  This  is  a greater  proportion  than  I have 
seen  mentioned  before,  but,  as  far  as  I can  ascertain, 
the  truth  is  stated.  What  causes  brought  about  the 
ulceration,  &c.,  in  the  forty-seven  patients  who  were 
not  syphilitic?  We  have  propounded  some  causes, 
viz.  tuberculosis  (not  so  uncommon  as  generally  sup- 
posed), dysentery  and  diarrhoea,  usually  following  pro- 
longed residence  in  tropical  climates ; obstinate  long- 
standing constipation,  injuries  to  the  uterus  and 
vagina  in  parturition,  operations  on  the  rectum  in 
persons  of  bad  constitution ; but  will  these  causes 
account  for  all  the  cases  ? I am  obliged  to  say  I do 
not  think  so,  and  to  confess  in  the  majority  of  these 
patients  I do  not  know  the  cause,  nor  have  I been 
able  to  trace  out  any  definite  common  state  preceding 


252 


STRICTURE  OF  THE  RECTUM 


the  malady.  If  we  could  answer  the  question  why 
ulceration  and  stricture  is  so  much  more  frequent  in 
the  female  than  in  the  male,  we  should  possibly  have  a 
clue,  but  for  my  part,  I cannot  see  that  any  satisfactory 
reply  has  been  given  to  this  question,  nor  has  it  to 
another  question : why  is  epithelioma  comparatively 
rarely  found  in  women  ? 

In  connection  with  this  part  of  the  subject,  I must 
say  a few  words  about  the  view  entertained  by  some 
French  authorities,  and  also  by  eminent  American 
surgeons,  viz.  that  the  vast  majority  (some  say  all)  of 
cases  of  stricture  and  ulceration,  not  cancerous,  result 
from  contamination  by  the  discharges  from  “ soft 
sores  ” or  ce  chancroids.’ 5 They  scarcely  admit  that 
constitutional  syphilis  has  anything  to  do  with  the 
cases  I have  been  considering  in  this  chapter.  When 
a former  edition  of  this  work  appeared,  I well  knew 
that  Dr  Gosselin,  of  Paris,  had  published  these  views, 
but  I knew  also  that  his  conclusions  had  been  arrived 
at  from  very  few  observations,  that  another  explana- 
tion of  his  cases,  which  I will  not  mention,  could  be 
readily  found,  and  that  his  theory  had  received  but 
feeble  support  from  any  of  his  confreres  while  many 
of  the  most  eminent  authors  on  syphilis,  as  Ricord, 
Fournier,  Molliere,and  others  had  altogether  repudiated 
his  doctrines.  These  I deemed  to  be  sufficient  reasons 
for  not  discussing  the  views  in  question,  but  since  I 
have  received  a monograph  from  Dr  Erskine  Mason, 
of  New  York,  who  adopts  Gosselin’ s views  in  their 
entirety,  I have  without  prejudice  considered  the  sub- 
ject, and  observed  my  cases  from  the  standpoint  Dr 
Mason  takes,  and  I must  state  that  I am  not  by  any 
means  convinced  by  Dr  Mason,  though  entertaining  a 


ULCERATION  OF  THE  RECTUM 


253 


very  liigh  sense  of  the  ability  and  spirit  with  which  his 
monograph  is  written. 

I think  I have  made  it  quite  clear  in  the  foregoing 
pages  that  in  both  sexes  the  most  intractable  ulceration 
and  stricture  of  the  rectum  may  arise  without  there 
being  any  venereal  element  whatever  in  its  causation,  and 
I think  I am  not  alone  in  this  view.  It  appears  from 
Dr  Mason’s  statistics,  as  well  as  my  own,  that  about 
half  the  patients  with  ulceration  and  stricture  “ have, 
or  have  had  ” constitutional  syphilis.  A fair  inference 
is,  I think,  that  some  form  of  syphilis  may  cause 
the  rectal  lesion.  Post-mortem  examinations  have 
revealed,  in  addition  to  rectal  ulceration,  deposits 
in  the  liver,  lesions  of  the  brain  and  membranes,  and 
diseases  of  bone ; at  least  probably  all  these  resulted 
from  the  same  cause;  but  I do  not  wish  for  one 
moment  to  maintain  that  in  every  case  when  syphilis 
and  ulceration  of  the  rectum  coexist  the  latter  is  caused 
only  by  the  former. 

It  is  no  sound  argument  to  say  that  if  the  ulcerations 
of  the  rectum  were  syphilitic  they  ought  to  yield  to  the 
usual  anti- syphilitic  remedies,  because  it  is  well  known 
that  the  latest  syphilitic  manifestations,  or  the  sequelae 
of  syphilis,  are  commonly  not  amenable  to  specific 
treatment,  whether  they  occur  in  one  or  other  organ, 
and  in  fact  the  time  has  passed  away  in  which  any  con- 
stitutional treatment  could  be  expected  to  have  much 
effect. 

Dr  Mason  says,  “ I have  repeatedly  noticed  the  anus 
become  contracted  in  women  after  the  healing  of 
several  simple  chancroids  involving  this  portion  of 
the  intestine.”  I must  say  I have  never  seen  such  a 
thing  myself. 


254 


STRICTURE  OF  THE  RECTUM 


How  can  the  discharge  from  a soft  sore  get 
into  the  anns  and  thence  to  the  rectum  ? by  the  dis- 
charge running  down  to  the  anus ; possibly,  but  I 
should  say  rarely.  Through  menstruation  ? more 
probably.  By  direct  contact  from  the  male  organ  ? 
most  probably.  In  France  this  cannot  be  uncommon, 
I trust  it  is  not  common  in  America.  I cannot  say  that 
in  this  country  it  is  altogether  unknown,  but  I hope 
and  think  it  is  infrequent.  I will  make  this  assertion 
without  fear  of  contradiction ; in  the  large  majority  of 
ulcerations  of  the  rectum  the  disease  does  not  com- 
mence at  the  anus , but  at  least  an  inch  up  the  bowel, 
a condition,  I would  say,  quite  incompatible  with  the 
theory  of  inoculation  from  external  discharge,  but  in 
accordance  with  what  one  might  expect  when  the 
discharge  was  implanted  by  direct  contact.  Dr  Mason’s 
own  statistics  bear  out  my  statement  as  to  the  usual 
site  of  the  ulcerating  stricture. 

Has  any  one  seen  soft  sores  on  any  part  of  the  body 
causing  induration  and  contraction  of  tissues  ? do  we 
see  this  in  soft  sores  under  a long  prepuce  ? Then, 
once  more,  how  does  phagedsenic  ulceration  accord 
with  contraction  and  fibroid  degeneration  of  tissue, 
which  is  one  of  the  essential  characteristics  of  advanced 
ulceration  and  stricture  ? 

Dr  Mason  asserts  that  he  has  seen  “ constriction  of 
the  rectum  follow,  and  that  very  shortly  after  the 
healing  of  chancroids  had  taken  place.”  I would  ask 
is  this  a pathological  probability ; and  is  the  post  hoc 
necessarily  the  propter  hoc  in  such  a case  ? 

I shall  but  cite  some  eminent  authorities  on  this 
very  interesting  subject,  as  space  is  wanting  for 
further  argument  and  observations.  Time,  I am  sure, 


ULCERATION  OF  THE  RECTUM 


255 


will  dispel  all  doubt,  but  at  present,  I think  we  may 
safely  say  that  the  chancroid  theory  does  not  account 
for  the  majority  of  strictures  and  ulcerations  of  the 
rectum. 

Ricord  has  expressed  the  opinion  that  many  cases 
of  stricture  were  caused  by  syphilitic  deposits  and 
ulceration.  Fournier  has  most  positively  asserted 
that  stricture  and  ulceration  of  the  rectum  were  com- 
monly caused  by  constitutional  tertiary  syphilis,  and 
most  rarely  by  local  contamination  of  any  kind.  Lan- 
cereaux,  in  his  book  on  4 Syphilis,  Historical  and  Prac- 
tical,5 states  that  gummata  have  been  found  in  the 
large  intestine,  and  although  inclined  to  agree  with 
Gfosselin,  and  regard  these  “ contractions  of  the 
rectum 55  rather  as  venereal  than  syphilitic,  yet 
would  not  too  exclusively  adopt  the  theory ; inasmuch 
as  gummy  deposits  are  found  in  other  parts  of  the 
intestinal  canal,  there  is  no  reason  why  they  should  not 
occur  in  the  rectum.  The  English  surgeons  most 
experienced  in  syphilis  almost  with  one  accord  adhere 
to  the  constitutional  theory,  and  discard  the  idea  of 
the  local  origin  of  ulceration  and  stricture  of  the  rectum. 
I have  spoken  to  scarcely  one  gentleman  who  has  not 
given  me  a similar  answer  to  my  questions  on  this 
point. 

My  friend  and  former  colleague,  Mr  James  R.  Lane, 
at  my  request  wrote  me  his  opinion  on  this  subject, 
and  I venture  to  submit  that  few  men  have  had  greater 
opportunities  for  studying  the  matter  than  he.  Many 
years  Surgeon  to  the  Hospital  for  Diseases  of  the 
Rectum,  the  worst  forms  of  stricture  and  ulceration 
are  perfectly  familiar  to  him ; for  a still  longer  period 
as  Surgeon  to  the  Female  Lock  Hospital  he  has  had  an 


256 


STRICTURE  OF  THE  RECTUM 


almost  unbounded  field  for  observing  every  kind  of 
sore  to  which  the  female  genitals  are  exposed,  and  what 
does  he  say  ? “ I believe  that  the  ulcerated  strictures  of 
the  rectum  to  which  you  allude,  and  with  which  I am 
so  familiar,  are  very  rarely,  I am  almost  disposed  to 
say  never , caused  by  primary  syphilitic  ulceration  of  the 
nature  of  soft  sores.  According  to  my  Lock  Hospital 
experience  by  far  the  most  common  seat  of  such  sores 
is  at  the  inferior  fourchette,  and  the  verge  of  the  anus. 
They  get  well  in  due  course  under  simple  treatment,  like 
soft  sores  generally  do ; sometimes,  when  situated  on 
the  sphincter  ani,  they  produce  the  pain  characteristic 
of  6 anal  fissure/  but  they  will  heal  all  the  same  and 
the  pain  will  disappear.  When  one  of  these  sores 
extends  into  the  rectum,  which  is  very  seldom  the 
case,  the  result  is  a circumscribed  rectal  ulcer,  which 
with  treatment,  and  especially  judicious  cauterisation, 
will  usually  heal.”  Mr  Lane  further  guards  himself 
against  being  sujjposed  to  consider  all  bad  ulcerations 
and  strictures  as  resulting  from  constitutional  syphilis. 
In  Mr  Lane’s  observations  I most  heartily  concur,  my 
experience  of  soft  sores  near  the  anus  is  that  they 
speedily  heal  under  proper  treatment,  and  I have  seen 
many  cases  cured  in  a few  days  by  cleanliness  and  the 
use  of  a tartrate  of  iron  lotion,  and  though  these 
patients  have  been  seen  from  time  to  time  for  other 
ailments,  no  ulceration  or  stricture  of  the  rectum  has 
been  found  to  ensue. 

Mr  Walter  Coulson,  Surgeon  to  the  Lock  Hospital, 
has  never  seen  ulceration  and  stricture  result  from  a 
soft  sore,  nor  has  my  colleague,  Mr  Alfred  Cooper, 
who,  like  Mr  Lane,  is  Surgeon  both  to  the  Lock 
Hospital  and  to  St  Mark's,  and,  therefore,  has  the 


ULCERATION  OF  THE  RECTUM 


257 


double  opportunity  of  noting  these  sores  from  an  early 
period  and  following  them,  if  they  came,  to  the 
Hospital  for  Diseases  of  the  Rectum  afterwards. 

Mr  Christopher  Heath,  of  University  College  Hos- 
pital, has  in  some  lectures  by  him  on  “ Diseases  of  the 
Rectum  ” strongly  expressed  his  conviction  that  the 
cases  we  have  been  discussing  are  commonly  the  result 
of  tertiary  syphilis.  Mr  Bryant,  in  his  e Practice  of 
Surgery,’  looks  upon  these  ulcerations  and  strictures 
“ as  mainly  syphilitic,”  and  only  thus  notices  Gosse- 
lin’s  views:  “ Foreign  authors  describe  chancroid  dis- 
ease of  the  rectum  venereal  but  not  syphilitic ; in  this 
country  it  is  hardly  recognised.” 

There  are  no  maladies  more  baffling  to  the  surgeon 
than  ulcerations  and  strictures  of  the  rectum,  and,  as 
I have  before  said,  they  are  often  quite  incurable,  and 
nothing  affords  relief  save  colotomy.  This  operation, 
however,  though  doubtless  it  may  prolong  life,  should 
not  be  resorted  to  without  due  consideration,  because 
one  cannot  fail  to  see  that  in  many  cases  the  remedy 
proves  a most  objectionable  one  ; an  opening  in  the  left 
loin  through  which  the  fasces  escape  is  very  harassing, 
and  nothing  but  a great  desire  to  live  or  the  fear  of  im- 
mediate death  would  lead  me  to  submit  to  such  a pro- 
ceeding. I presume  that,  as  time  goes  on,  the  patients 
get  used  to  the  discomfort  and  loathsomeness  of  their 
condition.  My  patients  who  have  lived  long  seem  to 
have  had  some  pleasure  in  life,  indeed,  two  women 
were  married  after  the  operation,  but  notwithstanding 
such  facts  as  these,  I entertain  greater  repugnance  to 
the  operation  than  I formerly  felt,  and  latterly  have 
mostly  performed  it  as  a last  resource  or  for  total 
obstruction.  It  is  not  quite  impossible  after  colotomy 

17 


258 


STRICTURE  OF  THE  RECTUM 


that  the  ulceration  and  stricture  may  get  well,  and 
then  the  wound  in  the  loin  might  be  closed;  this  I 
have  once  done,  but  although  I have  tried  I have  never 
succeeded  again.  In  the  earlier  stages  of  ulceration 
and  stricture  from  whatever  cause,  save  cancer,  treat- 
ment carefully  selected,  judiciously  varied,  and  persis- 
tently carried  out  may  do  much  good,  and  in  favorable 
cases  even  effect  a cure,  but  the  patient  must  have 
faith  in  his  surgeon,  and  be  prepared  to  submit  to  long- 
continued  watching  even  when  much  improved ; if  the 
sufferer  runs  about  from  one  doctor  to  another  his  fate 
is  sealed,  as  he  gives  neither  himself  nor  his  surgeon 
a chance. 

In  cases  of  circumscribed  ulceration,  I have  great 
confidence  in  the  efficacy  of  rest  in  the  recumbent 
position,  and  in  a wholly,  or  nearly,  fluid  diet,  and  I 
consider  milk  should  be  the  essential  element  in  such 
a diet.  I could  relate  many  cases  where  I have  really 
cured  the  patients  with  very  little  medication,  occa- 
sional slight  applications  of  a caustic  solution,  bismuth, 
morphia,  and  a gentle  regulation  of  the  bowels  having 
fulfilled  all  the  indications.  These  patients  confined 
to  the  sofa,  and  fed  almost  entirely  on  milk,  often 
improve  in  general  health,  and  gain  weight.  If  cod- 
liver  oil  can  be  taken  I prescribe  it  as  an  aid  to  nutri- 
tion, but  it  must  be  taken  only  in  small  doses. 

When  the  ulceration  is  deep,  and  contraction  has 
commenced,  the  disease  is  much  more  serious,  and  a 
very  doubtful  prognosis  should  be  given ; still  in  all 
cases  a good  deal  may  be  done,  and  hope  may  be  in- 
stilled, if  only  the  patient  will  give  up  all  to  treatment 
for  a more  or  less  lengthened  period.  If  patients  walk 
about,  stand,  sit,  and  attempt  to  continue  their  busi- 


To  face  p.  259 


Fig.  8. 

Improved  American  Ointment  Introducer. 


The  screw  (a)  being  removed,  the  tube  (b)  is  to  be  filled  with  the  oint- 
ment. On  introducing  the  instrument  into  the  rectum,  and  turning 
the  screw,  the  ointment  passes  out  of  the  apertures,  as  shown  at  c. 


ULCERATION  OF  THE  RECTUM 


259 


ness  transactions,  treatment  is  nearly  always  rendered 
inefficacious ; one  indiscretion  may  render  nugatory  a 
week’s  labour.  In  these  cases,  therefore,  rest  is  even 
more  important  than  in  ulceration  in  the  earliest  stage. 

Often  the  ulceration  induces  such  an  irritable  con- 
dition of  the  rectum,  that  nothing  will  be  retained, 
neither  any  injection,  suppository,  nor  ointment ; di- 
rectly anything  is  introduced,  uncontrollable  spas- 
modic expulsive  efforts  are  set  up,  and  may  continue 
long  after  the  offending  matter  is  rejected  ; thus  great 
pain  is  suffered  and  the  part  itself  damaged.  I have 
found  that  bismuth  and  charcoal  taken  internally  will 
generally  soon  overcome  this  excessive  irritability. 
Subcarbonate  of  bismuth  may  also  be  tried  on  the 
mucous  membrane  itself,  by  means  of  an  insufflator ; 
this  continuously  used  may  soothe  the  rectum  and 
relieve  pain.  As  a rule  I prefer  ointments  to  sup- 
positories or  injections.  The  little  instrument,  of 
which  a diagram  is  given,  obviates  all  difficulties  of 
introduction,  and  I am  sure  irritates  less  than  other 
methods  of  medication ; all  kinds  of  sedatives,  opiates, 
and  astringents  may  in  turn  be  tried.  I am  very  fond 
of  the  following  formula,  and  have  seen  it  most  effica- 
cious. Bismuth.  Subnitratis,  3ij  ; Hydrarg.  Subchlo- 
ridi,  9ij  ; Morphise,  gr.  iij  ; Glycerinm,  jjij  ; Vaseline,  gj ; 
this  is  a very  sedative  application,  and  sores  seem  to 
be  benefited  by  it  speedily.  Subacetate  of  lead,  bella- 
donna and  opium,  will  be  found  serviceable ; all  sorts 
of  astringents  may  be  employed ; rhatany,  friar’s 
balsam,  zinc  (the  permanganate),  copper,  iron,  nitrate 
of  silver,  &c.  The  last  carefully  used  in  not  too 
strong  solution,  is  one  of  the  most  admirable  applica- 
tions, often  inducing  in  an  ulcer  a healthy  appearance, 


260 


STRICTURE  OF  THE  RECTUM 


and  causing  granulation.  The  tartrate  of  iron  I also 
employ  for  the  same  purpose.  Fuming  nitric  acid  or 
strong  carbolic  or  chromic  acids  applied  under  certain 
conditions,  are  potent  remedies,  they  often  allay  pain 
and  start  healing  processes  afresh,  but  they  are 
double-edged  weapons  and  must  be  used  with  great 
discretion,  and  with  a distinct  object  in  view.  In 
ulceration,  when  the  least  stricture  exists,  bougies 
may  be  always  employed,  but  it  must  be  remembered 
that  to  do  any  good  the  greatest  gentleness  must  be 
practised  by  the  surgeon,  indeed,  pain  ought  not  to  be 
caused,  although  considerable  discomfort  cannot  in 
most  cases  be  avoided.  A bougie  of  too  large  a size 
should  never  be  employed  ; no  greater  mistake  can  be 
made,  than  to  suppose  that  the  larger  the  bougie  you 
can  get  in  the  better ; keep  below  the  size  that  can  be 
well  borne  rather  than  at  all  above  it ; in  the  one  case 
good  may  ensue,  in  the  other,  irritation  and  retro- 
gression are  sure  to  take  place ; never  give  a patient  an 
ordinary  bougie  to  use  for  himself,  if  the  stricture  be 
more  than  two  inches  from  the  anus.  I have  now  seen 
two  deaths  occur  from  patients  thrusting  the  instru- 
ment through  the  wall  of  the  rectum ; peritonitis  im- 
mediately set  in,  and  they  expired  in  great  agony. 
Occasionally,  when  the  constriction  is  only  about  an 
inch  or  an  inch  and  a half  from  the  anus,  I let  the 
patient  have  a short  instrument  to  pass  and  wear  at 
night,  if  its  introduction  can  be  accomplished  without 
any  severe  pain.  I employ  vulcanite  tubes  furnished 
with  a collar,  to  which  tapes  are  fastened  to  keep  them 
in  the  bowel,  and  at  the  same  time,  prevent  them 
escaping  into  the  rectum,  an  accident  I have  more  than 
once  seen  occur ; in  one  case,  indeed,  a full-sized  long 


ULCERATION  OF  THE  RECTUM 


261 


bougie  entirely  disappeared,  and  could  not  be  reached 
by  the  finger  in  the  rectum,  its  distal  end  could  be  felt 
in  the  transverse  colon ; fortunately,  after  a few  trials, 
I was  able  to  seize  it  with  a pair  of  long  bullet  forceps, 
and  withdrew  it  from  the  bowel ; the  patient,  as  may 
well  be  imagined,  being  not  a little  frightened.  When 
strictures  are  slight,  and  not  very  long  but  annular,  a 
division  in  a few  places  with  the  knife,  followed  by 
judicious  treatment  with  the  tubes,  may  be  very  bene- 
ficial and  even  curative.  The  division  I usually  make 
at  four  points,  and  I take  care  just  to  cut  through  the 
induration,  and  reach  the  healthy  tissues  beneath,  but 
not  to  go  deeper  ; the  bowel  should  be  filled  with  well- 
oiled  lint  or  wool  for  twenty-four  hours,  and  then  the 
tube  introduced  and  worn,  only  taking  it  out  for  the 
bowels  to  act,  and  to  wash  out  the  rectum  with  some 
antiseptic  solution.  I prefer  Condy’s  fluid  very  dilute 
or  thymol.  I am  of  opinion  that  carbolic  acid  is 
always  too  irritant,  if  strong  enough  to  be  of  any 
service. 

Some  four  years  ago  a young  gentleman,  set.  19, 
came  to  me  with  an  annular  stricture  about  an  inch 
from  the  anus ; division  as  I have  described,  the  use 
of  the  tube,  and  general  treatment  cured  him  in  six 
months,  and  he  has  continued  quite  well  to  this 
day. 

Continuing  to  consider  the  progress  of  these  cases, 
we  come  to  the  more  severe  kind  where  the  ulceration 
is  very  extensive,  the  constriction  so  bad  that  there  is 
great  difficulty  in  obtaining  any  passage  through  the 
bowels  ; no  action  taking  place  without  the  use  of 
strong  purgatives,  or  where,  on  the  other  hand,  incon- 
tinence of  faeces  renders  the  patient’s  life  a burden  to 


262 


STRICTURE  OF  THE  RECTUM 


him.  The  lower  part  of  the  rectum  will  be  now  merely 
a passive  tube,  ail  elasticity  has  gone,  and  liquid  fmces 
run  away,  or  there  is  a perpetual  leaking  of  semi-fluid 
motion  ; the  condition  of  the  sufferer  is  truly  pitiable, 
around  the  anus  large  hard  growths  exist,  and  fistu- 
lous passages  pass  up  the  bowel  opening  into  the  ulcer- 
ation, most  frequently  below  but  sometimes  above 
the  seat  of  constriction.  These  fistuke  may  be  divided, 
and  some  temporary  relief  afforded.  If  in  such 
cases  the  fistulas  run  high  up  the  bowel,  and  the 
tissues  are  very  dense,  I much  prefer  the  elastic  liga- 
ture to  the  knife ; in  fact  I now  never  employ  the 
latter  in  such  a case  ; the  bleeding  is  sure  to  be  exceed- 
ingly free  at  the  time,  and  great  difficulty  is  found  in 
arresting  it,  as  the  vessels  can  neither  retract  nor 
contract.  The  only  patient  I ever  lost  from  haemor- 
rhage after  an  operation  upon  a fistula  was  a young 
and  delicate  man  sent  to  me  from  Ireland  with  stricture 
and  numerous  fistulae,  the  whole  tissues  being  brawny 
in  the  extreme.  At  the  operation  I had  great  difficulty 
in  arresting  the  bleeding,  but  concluded  that  all  was 
safe ; unfortunately,  in  the  evening  there  was  a recur- 
rence, and  my  colleague,  Mr  Goodsall,  succeeded  in 
stopping  it  with  plugging  and  styptics ; however,  on 
the  third  morning  a sudden  gush  took  place,  and  the 
man  died  at  once.  The  induration  of  the  parts  pre- 
vented the  application  of  any  ligatures ; they  cut 
through,  or  the  vessel  was  so  deeply  placed  as  to  be  out 
of  reach. 

In  these  later  stages  of  ulceration  no  good  is  derived 
from  constitutional  treatment.  Mercury  in  any  form 
does  harm.  Iodide  of  potassium  is  unavailing.  Tonics 
to  maintain  appetite,  and  give  tone  to  the  nervous 


ULCERATION  OF  THE  RECTUM 


263 


system  may  be  used,  and  always  cod-liver  oil,  which 
may  be  regarded  as  concentrated  nourishment ; one 
need  not  say  that  good  feeding  with  nutritious,  but  not 
bulky  food  is  required.  I shall  discuss  more  fully 
lumbar  colotomy  in  my  chapter  on  cancer. 

Stricture  of  the  rectum  without  ulceration  is  a 
somewhat  uncommon  affection.  We  have  seen  how 
stricture  takes  place  after,  or  in  conjunction  with, 
ulceration.  The  thickening  of  the  tissues  and  the 
contractions  which  result  from  the  attempts  at  repair 
must  narrow  the  canal,  but  it  is  not  so  easy  to  see 
how  or  why  a stricture  should  occur  per  se.  The 
rectum  is  a tolerably  large  tube  (not  like  the 
urethra,  where  a very  little  deposit  is  sufficient  to 
nearly  block  up  the  passage),  and  a considerable 
thickening  might  take  place  without  causing  any  great 
obstruction. 

We  may,  perhaps,  suppose  that  inflammation  of  the 
submucous  tissue  produces  a deposition,  and,  besides 
this,  or  resulting  from  this,  there  is  spasm.  I am  sure 
this  is  often  the  case ; I have  seen  strictures  of  the 
rectum  so  tight  that  I could  not  get  the  end  of  my 
little  finger  into  them,  but  when  the  patients  were  well 
under  the  influence  of  chloroform  I have  been  able  to 
pass  one  or  two  fingers  through  easily. 

How  inflammation  and  thickening  are  set  up  in  the 
connective  tissue  of  the  bowel  it  is  difficult  to  say.  It 
may  be  that  straining  to  evacuate  the  contents  of  the 
bowel  forces  down  the  upper  part  of  the  rectum  into 
the  lower,  thus  causing  an  intussusception,  and  bring- 
ing the  part  within  the  grasp  of  the  sphincter 
muscles,  and  I have  often  thought  that  this  condition 
may  be  the  starting-point  of  the  irritation. 


264 


STRICTURE  OF  THE  RECTUM 


I have  in  some  few  cases  had  a suspicion  that  the 
long-continued  pressure  of  the  child’s  head  in  labour 
has  been  the  exciting  cause,  bruising  of  the  bowel 
having  perhaps  taken  place. 

Possibly,  also,  inflammation  may  be  induced  by  the 
passage  of  very  dry  and  hardened  faeces,  though  doubt- 
less this  condition  may  obtain  for  years — as  it  often 
does  in  old  people — without  producing  stricture. 

I have  seen  one  case  in  which  the  frequent,  and 
perhaps  rather  rough,  use  of  an  enema  pipe  produced 
a stricture.  This  occurred  in  an  elderly  lady  who  had 
for  years  given  herself  an  injection  daily.  She  did  not 
at  first  suffer  from  constipation,  but  she  had  been 
recommended  an  enema,  and  at  last  she  could  not  get 
an  action  without  it.  I thought  in  this  instance  it  was 
not  improbable  that  the  passage  of  the  bone  tube  had 
been  the  exciting  cause  of  inflammatory  thickening  of 
the  bowel. 

It  may  perhaps  be  said  that  I have  assumed  inflam- 
mation to  be  the  cause  of  the  exudation  into  the  wall 
of  the  bowel.  I must  confess  that  I have,  for  I have 
rarely  been  able  to  detect  decided  symptoms  of  inflam- 
mation of  the  rectum  preceding  stricture.  I have 
constantly  asked  patients  whether  they  have  at  any 
time  suffered  from  pain,  sensation  of  burning,  diar- 
rhoea, dysentery,  or  discharge  of  matter  from  the 
bowel,  and  the  reply  has  most  usually  been  in  the 
negative.  On  the  other  hand,  I have  seen  cases  of 
long-continued  proctitis,  especially  in  aged  people,  not 
followed  by  stricture.  The  coarse  symptoms  of  stric- 
ture viz.  straining  and  difficulty  in  discharging  the 
motions,  have  been  already  described.  It  is  stated 
in  some  works  that  the  stools  are  thin,  long,  and 


ULCERATION  OF  THE  RECTUM 


265 


pipe-like.  According  to  my  experience  this  is  not 
usually  the  case  in  true  stricture ; spasm  of  the 
sphincter,  enlarged  prostate  gland,  and  tumours  of 
the  pelvis,  much  more  frequently  give  rise  to  flattened 
and  thin  motions.  The  most  characteristic  feature  in 
my  opinion  is  the  passage  of  numerous  very  small 
broken  pieces ; the  faeces  having  no  actual  form,  and 
looseness  often  alternating  with  this  lumpy  condition. 
The  discharge  in  simple  stricture  is  like  the  white  of 
an  unboiled  egg  or  a jelly-fish,  and  is  passed  when  the 
bowels  first  act.  There  is  no  coffee-ground  looking 
discharge  so  constantly  seen  in  ulceration,  nor  is  there 
the  morning  diarrhoea  which  we  get  in  that  complaint. 
There  is  very  rarely  any  pain  experienced  in  the  bowel 
itself,  the  symptoms  are  generally  referred  more  or 
less  to  distant  parts,  notably  the  penis,  perineum, 
bottom  of  the  back,  the  thighs,  beneath  the  buttocks, 
and  occasionally  the  stomach.  Fortunately  strictures 
of  the  lower  bowel  are  generally  within  reach  and 
sight,  but  occasionally  they  are  found  high  up  in  the 
sigmoid  flexure,  or  still  more  distant  from  the  anus. 
In  these  cases  it  becomes  a matter  of  great  import- 
ance to  ascertain  the  situation  of  the  obstruction,  but 
this  is  a question  I shall  not  enter  upon  here. 

A stricture  of  the  rectum  resulting  entirely  from 
muscular  spasm  is  what  I am  very  much  disinclined 
to  believe  in.  I do  not  deny  that  such  a condition  may 
be  found,  but  to  me  it  appears  to  be  very  improbable, 
and  I feel  confident  that  in  many  of  the  supposed 
spasmodic  strictures  there  is  really  no  constriction  at 
all.  The  operator  has  been  misled  by  the  bougie 
catching  in  a fold  of  the  gut  or  against  the  promon- 
tory of  the  sacrum.  If  you  are  in  doubt  about  the 


266 


STRICTURE  OF  THE  RECTUM 


existence  of  a stricture,  you  should  use  a long  and  very 
elastic  enema  tube  and  inject  fluid  as  you  pass  it,  so 
as  to  distend  the  gut  and  remove  any  intussusception 
of  the  upper  part  of  the  rectum.  This  condition,  I 
think,  has  often  been  mistaken  for  stricture,  as,  unless 
the  bougie  goes  directly  into  the  aperture  of  the  de- 
scended portion  of  gut,  it  gets  into  the  sulcus  at  the 
side,  which  is  a cul-de-sac,  and  the  instrument  cannot 
be  made  to  pass.  I have  satisfied  myself  on  several 
occasions  of  the  existence  of  this  source  of  error. 

For  some  years  past  in  exploring  the  rectum  for 
stricture  I have  used  vulcanite  balls  of  different  sizes, 
mounted  on  pewter  stems  with  flattened  handles ; they 
are  easily  bent  into  any  form,  they  will  even  bend  in 
the  bowel,  and  by  their  use,  as  in  exploring  the  urethra, 
you  may  make  certain  of  detecting  a stricture.  For 
when  they  pass,  or  on  gently  withdrawing  them,  the 
ball  is  felt  to  come  suddenly,  and  perhaps  with  some 
difficulty,  through  the  constriction.  Its  length  also 
can  be  approximately  measured. 

In  cases  of  stricture  when  there  is  great  spasm 
with  a small  amount  of  organic  disease,  much  good 
may  be  done  by  the  use  of  bougies.  Before  passing 
the  bougie,  it  is  well  to  inject  into  the  bowel  some 
sedative,  as  opium  or  belladonna  with  oil,  and  to  use  a 
stiff  lubricant  on  the  bougie  (such  as  blue  ointment) ; 
if  the  instrument  cannot  be  quickly  passed,  it  is  better 
not  to  persevere,  as  irritation  will  be  set  up  and 
damage  done ; once  set  up  the  spasm  and  all  your 
endeavours  may  be  frustrated,  the  stricture  must  as  it 
were  be  surprised.  I do  not  like  any  forcible  dilata- 
tion in  these  cases ; you  may  tear  or  split  the  stricture 
with  Todd’s  dilator,  but  you  are  more  likely  to  get 


ULCERATION  OF  THE  RECTUM 


267 


ulceration  than  permanent  benefit  to  the  stricture. 
On  the  same  principle  I should  not  cut  even  in  the 
slightest  degree  any  constriction  where  no  ulceration 
existed,  save  in  cases  I will  describe.  If  the  stricture 
is  high  up,  the  use  of  Todd’s  dilator  is  dangerous.  I 
have  seen  profuse  haemorrhage  follow  its  use,  and  the 
bowel  might  be  torn  to  the  injury  of  the  peritoneum, 
especially  in  women. 

In  these  cases  I am  also  of  opinion,  that  retaining  a 
bougie  or  tube  is  not  usually  advantageous ; you  may 
produce  ulceration,  and  if  this  should  be  done  you  will 
perhaps  irretrievably  damage  your  patient.  Gentle 
dilatation,  very  gradually  increasing  the  size  of  the 
instrument,  is  the  only  safe  treatment.  The  conical 
bougie  is  a good  form,  as  gentle  pressure  induces  this 
to  enter  the  stricture  more  easily,  but  you  should 
never  cause  pain,  and  you  may  be  sure  that  if  blood 
or  mucus  passes  after  your  manipulation,  your  patient 
will  have  little  to  thank  you  for. 

I used  to  think  that  twice  in  the  week  or  at  most 
three  times,  was  as  often  as  the  instrument  ought  to 
be  used,  but  in  obstinate  cases  its  daily  use  has  in  my 
more  recent  experience  been  followed  by  greater  per- 
manent good.  Still,  in  this  matter  every  case  must  be 
judged  on  its  own  merits,  bearing  in  mind  the  axiom 
“ never  irritate.” 

A bad  form  of  stricture,  fortunately  of  rare  occur- 
rence, is  that  in  which  the  constriction  is  semicircular 
or  annular,  and  feels  to  the  touch  as  though  the  bowel 
were  encircled  by  a cord.  These  strictures  are  so  resi- 
lient that  even  if  dilated  to  their  fullest  extent,  they 
very  soon  return  to  their  previous  state  of  contraction. 
It  is  in  these  alone  that  I consider  division  advisable, 


268 


STRICTURE  OF  THE  RECTUM 


but  the  incisions  should  be  only  superficial,  and  dilata- 
tion should  be  commenced  on  the  day  following  the 
operation. 

When  a stricture  is  well  dilated  the  patient  gene- 
rally experiences  the  greatest  amount  of  relief  ; there  is 
no  more  straining  at  stool ; comfortable  good-sized 
motions  are  passed,  and  many  anomalous  symptoms 
vanish.  One  drawback  is  the  rapidity  with  which  all 
strictures  are  apt  to  return  ; the  relief  afforded  is  even 
much  less  durable  than  that  obtained  in  stricture  of 
the  urethra  ; the  patient  should  therefore  be  warned 
never  to  be  long  without  having  the  bougie  passed, 
and  certainly,  directly  any  of  his  old  symptoms  recur, 
at  once  to  obtain  treatment;  if  this  advice  be  acted 
upon,  but  little  fear  need  be  entertained  of  a dangerous 
relapse. 


CHAPTER  XVIII 


CANCER  OF  THE  RECTUM 

There  are  very  few  parts  of  the  human  body  which 
may  not  be  attacked  by  cancer,  but  some  are  more 
frequently  affected  than  others,  and  the  rectum  is  one 
of  the  favourite  sites  of  this  disease.  Cancer  is,  in 
the  vast  majority  of  cases,  a fatal  disease,  and  when 
the  rectum  is  the  part  affected  it  usually  runs  its 
course  in  about  two  years.  In  many  instances  the 
duration  of  life  is  much  less.  I have  watched  a case 
of  encephaloid  which  terminated  fatally  at  the  end  of 
four  months  from  the  earliest  symptoms  of  its  inva- 
sion. Colotomy  was  performed  by  me  when  I first 
saw  the  patient,  two  months  before  death  ; but  in  my 
opinion  it  did  not  delay  the  progress  of  the  disease 
one  day,  although  it  afforded  relief  from  excruciating 
pain.  On  the  other  hand,  I have  seen  a case  of  scir- 
rhus  on  the  anterior  wall  of  the  rectum,  in  which  the 
patient  lived  about  four  years  and  a half.  I will 
briefly  record  the  case. 

A man,  of  not  at  all  unhealthy  appearance,  came 
under  my  care  at  St  Mark’s  Hospital  in  the  year 
1865.  He  had  suffered  more  or  less  from  symptoms 
of  obstruction  in  the  bowel  for  five  or  six  months. 
An  examination  per  anum  detected  a hard,  solid  mass, 
appearing  to  rise  from  the  neighbourhood  of  the 


270 


CANCER  OF  THE  RECTUM 


prostate  gland ; it  blocked  up  the  whole  rectum ; the 
surface  was  irregular,  but  not  ulcerated  at  all.  I 
thought  it  might  possibly  be  a hydatid,  although  no 
fluctuation  could  be  detected ; a long  exploring  trocar 
thrust  into  it  did  not  reach  any  fluid.  He  had 
suffered  entire  constipation  for  twenty  days,  and  his 
symptoms  were  so  urgent  that  I at  once  performed 
colotomy.  He  returned  home  in  six  weeks  feeling  very 
well,  and  he  lived  for  four  years  and  a half,  dying  at 
last  from  the  extension  of  the  disease  to  the  bladder 
and  consequent  exhaustion. 

Cancer  is  commonly  a disease  of  middle  life,  but  I 
have  seen  encephaloid  rapidly  fatal  in  a boy  of  seven- 
teen ; and  some  years  ago  there  was  in  St  Mark’s 
Hospital,  under  the  care  of  my  colleague  Mr  Gowlland, 
a boy,  not  thirteen,  with  cancer  of  the  rectum.  Scir- 
rhus  and  epithelioma  are  not  very  uncommon  in  old 
people,  and  in  them  usually  run  a very  slow  course, 
which  may  be  accounted  for  by  the  fact  that  in  old 
persons  the  vital  forces  are  sluggish. 

It  has  been  said  that  cancer  is  more  frequent  in 
women  than  in  men.  As  regards  the  rectum,  this  is 
directly  the  reverse  of  my  experience.  In  my  statistics 
many  more  men  are  victims  than  women. 

I am  in  accord  with  those  who  do  not  consider 
cancer  as  an  hereditary  malady ; it  is  true  that  there 
are  very  few  families  in  which  cancer  has  not 
appeared,  more  or  less  remotely,  but  that  is  only 
because  cancer  in  some  form  is  so  common  in  human 
beings.  Although  I always  put  the  question,  it  has 
comparatively  rarely  happened  to  me  to  find  that  the 
father  or  mother,  or  even  grandfather  or  grandmother, 
has  suffered  from  the  disease.  Often  uncles  or  aunts, 


CANCER  OF  THE  RECTUM 


271 


or  brothers  or  sisters,  and  still  oftener  cousins  and 
more  distant  relations  have  suffered  from  cancer ; but 
the  question  of  heredity  is  not  thereby  affected. 

Some  varieties  of  cancer  may  in  their  early  stage  be 
only  and  purely  local ; but  I am  afraid  that  stage  is  of 
very  short  duration,  and  that  the  above  statement  is 
hardly,  certainly  not  practically,  true  of  the  more 
malignant  forms.  By  this  I mean  that  as  soon  as  a 
growth  exhibits  itself,  so  as  to  be  noticed  by  the 
patient,  the  disease  is  already  constitutional,  and  the 
system  is  infected. 

As  a rule,  cancer  of  the  rectum  is  most  horribly 
painful,  the  function  of  the  part  enhancing  the 
suffering;  but  I have  seen  patients  in  whom  there 
has  not  been  excessive  pain,  particularly  in  the  early 
period.  In  the  more  advanced  stages  of  the  malady 
the  pain  often  becomes  unremitting,  from  the  fact 
that  many  nerves  become  involved,  and  are  pressed 
upon  or  stretched,  the  neighbouring  organs  thus 
becoming  seats  of  separate  pain,  even  if  they  are  not 
actually  touched  by  the  growth.  I had  a patient  with 
cancer,  which,  commencing  in  the  rectum,  involved 
the  whole  cavity  of  the  pelvis,  and  pain  down  the 
right  sciatic  nerve  was  one  of  her  most  distressing 
symptoms. 

The  forms  of  malignant  disease  usually  described 
are  epithelioma,  scirrhus,  encephaloid,  colloid,  and 
melanosis.  I think  I have  placed  them  in  their  order 
of  frequency.  I have  never  seen  a melanotic  tumour 
of  the  rectum.  I have  seen  many  colloid  tumours, 
but  I am  not  sure  that  encephaloid  may  not  be  colloid, 
or  pass  into  it.  From  my  own  clinical  observations  I 
should  be  inclined  to  say  that  in  cancer  of  the  rectum 


272 


CANCER  OF  THE  RECTUM 


it  is  often  very  difficult,  if  even  possible,  to  make  any  dis- 
tinction between  epithelioma  and  broken  down  scirrhus. 
I have  seen  cancers  of  the  rectum  stony  hard  at  one 
part  and  quite  soft  at  another. 

Malignant  growths  are  commonly  found  seated  within 
three  inches  of  the  anus,  the  most  rapidly  dangerous 
being  higher  up,  about  the  lower  portion  of  the  sigmoid 
flexure.  When  cancer  occurs  near  the  anus  it  may 
extend  upwards  beyond  the  reach  of  the  finger,  but 
more  frequently  it  does  not,  and  the  whole  extent  of 
the  disease  can  be  ascertained.  It  is  but  rare  that 
any  form  of  cancer  commences  at  the  anus  itself — I 
have  seen  some  cases  of  epithelioma,  but  compara- 
tively few — nor  as  a rule  does  the  cancer  come  gradu- 
ally down  to  the  anus  ; in  the  very  latest  stages  it  may 
do  so,  but  this  is  the  exception.  When  it  does  come 
down  to  the  anus  it  is  generally  mistaken  for  piles, 
and  caustics  are  applied,  to  the  aggravation  of  the 
patient’s  suffering.  There  is  something  peculiar  about 
the  feel  of  cancer  which  the  practised  finger  rarely 
mistakes  even  for  simple  indurated  ulceration.  I think 
it  is  many  years  now  since  I mistook  the  one  for  the 
other.  There  is  also  a peculiar  odour  which  one  can- 
not describe,  but  which  once  recognised  will  rarely  be 
forgotten.  In  my  opinion  the  odour  is  pathogno- 
monic. 

Scirrhus  and  encephaloid  commence,  according  to 
my  clinical  experience,  in  the  submucous  tissue,  and 
the  mucous  membrane  may  for  a time  remain  quite 
smooth  and  unaffected,  though  adherent  to  the  growth 
beneath. 

In  epithelioma  the  mucous  membrane  seems  from 
the  first  to  be  the  seat  of  the  disorder,  and  even  when 


CANCER  OF  THE  RECTUM 


273 


the  growth  and  thickening  have  become  considerable, 
the  whole  will  be  found  freely  movable  over  the  struc- 
tures beneath.  In  scirrhus  and  encephaloid  this  is 
not  the  case ; very  early  in  the  disease  it  has  spread 
more  deeply,  and  in  many  instances  seems  very 
immobile. 

Scirrhus  is  often  found  as  a hard  tumour  seated  in 
the  rectum  over  the  prostate  gland,  and  although  it 
may  not  have  arisen  from  the  gland  itself  nor  invaded 
it  at  all,  yet  it  is  remarkably  adherent  to  it.  In  a case 
in  which  I removed  a scirrhous  nodule,  about  the  size 
of  a large  cherry,  from  this  situation,  I was  obliged 
to  dissect  off,  with  the  growth,  the  fibrous  capsule 
of  the  prostate  itself.  On  microscopic  examination 
the  tumour  was  declared  to  be  true  scirrhus  by  my 
friend  Dr  Wm.  Ord.  The  patient  recovered  from  the 
operation,  and  I have  not  heard  of  him  since,  but 
I should  expect  that  the  growth  will  almost  certainly 
recur. 

The  more  malignant  forms  of  cancer  do  not  exist 
very  long  in  the  rectum  before  they  poison  the  blood 
generally,  and  cause  secondary  deposits  in  the  lumbar 
glands,  groin,  liver,  &c.  The  aspect  of  countenance 
which  so  often  attends  the  cancerous  cachexia  is  very 
usual,  and  seen  earlier  in  cancer  of  the  rectum  than 
in  the  same  disease  of  other  parts.  In  cancerous 
growths  high  up,  vomiting,  frequent  and  severe,  is  an 
early  symptom,  even  when  not  much  obstruction  exists. 
The  onset  of  cancer  in  the  rectum  is  often  marked  by 
very  trivial  symptoms,  hence  the  disorder  comes  upon 
you  as  a surprise.  A patient  may  come  into  your  consult- 
ing-room complaining  of  no  more  than  a little  uneasi- 
ness in  the  bowel  or  a slight  morning  diarrhoea.  He 

18 


274 


CANCER  OF  THE  RECTUM 


may  look  thoroughly  healthy  and  strong,  and  may 
really  think  himself,  save  for  the  slight  local  trouble, 
perfectly  well,  yet  on  making  an  examination  you  find 
the  disease  advanced  beyond  all  possibility  of  doing 
any  good. 

An  elderly  Scotch  gentleman  was  sent  to  me  by  Dr 
Nisbett,  of  Gravesend.  To  all  appearance  he  was  the 
wiry,  healthy-looking  Scot.  “ Hard  as  nails,”  he  said 
he  was,  but  he  was  a little  troubled  by  irregular  action 
of  the  bowels — sometimes  costive,  sometimes  loose — 
and  he  occasionally  passed  a little  blood.  On  exami- 
nation I found  what  I really  did  not  expect,  a hard 
scirrhous  mass  in  the  rectum,  extending  higher  up  the 
bowel  than  I could  reach.  By  sheer  power  of  con- 
stitution he  lived  a little  more  than  twelve  months 
from  that  interview. 

In  October,  1878,  Mr  Wilton,  of  Sutton,  sent  a gen- 
tleman, set.  84,  to  me.  He  was  suffering  from  some 
pain  in  the  back,  with  a weary  sensation  after  exer- 
tion; had  small  losses  of  blood  at  stool  and  rather 
frequent  motions,  always  in  the  morning  and  some- 
times at  night.  His  idea  was  that  he  had  piles.  On 
examination  I found  an  epithelioma  commencing  just 
within  reach  of  the  finger,  and  extending,  as  I found 
by  careful  sounding,  at  least  two  inches  higher  up. 
The  growth  was  causing  some  contraction  of  the  bowel. 
This  patient  was  afterwards  the  subject  of  secondary 
deposits  in  the  liver.  He  died  in  October,  1881. 

When  cancer  attacks  the  uppermost  portion  of  the 
rectum  or  the  sigmoid  flexure,  the  disease  generally 
runs  a more  rapid  course,  and  is  much  more  dan- 
gerous; indeed,  sudden  death  is  not  uncommon,  as 
total  obstruction  takes  place  quickly,  and  unless 


CANCER  OF  THE  RECTUM 


275 


colotomy  is  promptly  performed  the  intestine  gives 
way  above  the  obstruction,  and  death  ensues.  I have 
seen  a good  many  examples  of  this,  and  always  warn 
the  friends  of  what  may  happen.*  Cancerous  stricture 
of  the  upper  part  of  the  sigmoid  flexure  or  the  descend- 
ing colon  is  not  so  immediately  dangerous,  although 
the  obstruction  may  be  total.  I saw  with  Mr  Sutton 
Sams,  of  Lee,  an  elderly  lady,  who  had  total  obstruc- 
tion high  up  the  bowel,  and  yet  lived  for  more  than 
eight  weeks.  Another  case  I saw  in  consultation 
with  Mr  John  M.  Burton,  also  of  an  elderly  lady,  who 
had  a similar  obstruction  and  lived  for  many  weeks, 
though  she  had  constant  vomiting.  Many  cases  of 
this  kind  have  come  under  my  notice  where  patients 
would  not  submit  to  colotomy.  I need  not  say  that 
their  suffering  is  very  great  and  loudly  calls  for 
surgical  interference.  At  the  same  time  the  difficulty 
of  ascertaining  the  precise  seat  of  the  obstruction,  in 
many  instances,  ties  the  surgeon’s  hands. 

I now  come  to  the  consideration  of  a very  im- 
portant but  unsatisfactory  part  of  my  subject : viz. 
What  can  one  do  for  the  relief  of  these  terribly 
unfortunate  persons  ? 

I have  never  seen  any  benefit  result  from  the  appli- 
cation of  caustics  to  growths  within  the  bowel,  but 
when  a cancerous  mass  protrudes,  which,  however,  is 
a somewhat  rare  occurrence,  I have  relieved  pain  and 
got  rid  of  a good  deal  of  the  growth  by  using  the 
arsenite  of  copper  with  mucilage  as  a paste,  this 
destroys  rapidly  without  increasing  the  suffering  at 

* Sir  James  Paget  related  a case  to  me  where  very  little  was  thought 
to  he  the  matter  with  the  patient  until  nine  days  before  entire  ob- 
struction took  place  and  death. 


276 


CANCER  OF  THE  RECTUM 


the  time  ; it  does  not  cause  bleeding,  and,  as  far  as  my 
experience  goes,  it  is  free  from  danger. 

The  treatment  in  the  majority  of  cases  of  cancer 
still  resolves  itself,  for  the  most  part,  into  an  attempt  to 
assuage  the  suffering  of  the  patient.  Pain  is  generally 
mitigated  by  the  recumbent  posture,  and  good,  easily 
assimilated,  nourishing  diet,  with  alcohol  in  moderate 
quantities.  All  varieties  of  sedatives  may  be  used 
with  benefit  externally  and  internally,  and  when  one 
drug  loses  its  effect  another  should  be  substituted. 
Opium  in  its  several  forms  is  the  most  effective  agent 
we  possess.  It  may  be  used  as  a suppository,  in 
which  case  the  best  formula  is  morphia  with  glycerine 
and  gelatine  (three  of  glycerine  to  one  of  gelatine),  as 
this  melts  very  soon,  and  does  not  feel  like  a foreign 
body  in  the  sensitive  bowel  as  suppositories  made  of 
cacao  butter  so  frequently  do ; injections  of  Battley’s 
sedative,  nepenthe,  or  black  drop  in  starch,  sometimes 
afford  great  relief.  Solid  opium  by  the  mouth  is  a 
great  favourite  with  me,  but  the  objection  to  it  is  that 
the  stomach  gets  irritated,  the  appetite  fails,  and  the 
bowels  are  confined.  Probably  most  patients  obtain 
the  greatest  comfort  from  hypodermic  injections  of 
morphia,  but  no  opiate  can  be  used  long  without 
inducing  a state  of  mind  almost  as  unendurable  as  the 
pain  of  the  disease,  and  therefore  great  care  should  be 
taken  to  husband  the  remedy  as  much  as  possible, 
never  using  a larger  dose  than  is  absolutely  necessary, 
bearing  in  mind  that  you  may  have  to  rely  upon  it 
more  or  less,  even  for  months.  I have  had  many 
patients  who  from  small  beginnings  got  to  inject  from 
eight  to  fifteen  grains  of  morphia  in  the  twenty-four 
hours,  and  the  condition  of  mind  of  these  patients  was 


CANCER  OF  THE  RECTUM 


277 


really  fearful.  Many  persons  who  had  injected  such 
large  doses,  have  told  me  that  they  preferred  the  most 
excruciating  pain  to  the  mental  distress  the  morphia 
produced,  and  have  even  of  their  own  accord  left  off 
the  drug  and  endured  the  physical  suffering. 

It  has  recently  been  asserted  by  Mr  John  Clay,  of 
Birmingham,  that  Chian  turpentine  has  a curative  action 
in  certain  cases  of  cancer.  Following  Mr  Clay’s  method, 
I have  administered  this  drug  in  forty-nine  cases  of 
malignant  disease  of  the  rectum,  many  of  the  patients 
taking  it  for  several  months,  even  up  to  a short  time 
before  death.  The  turpentine  was  genuine,  being 
obtained,  for  the  most  part,  from  the  chemists  recom- 
mended by  Mr  Clay ; in  only  two  cases  did  I see  the 
slightest  mitigation  of  symptoms.  Both  these  patients 
took  the  medicine  for  nearly  twelve  months,  but  the 
improvement  was  quite  evanescent  and  the  patients 
died.  In  all  the  other  cases,  either  no  effect  was 
manifested  or  only  a bad  one,  viz.  nausea  and  frequent 
derangement  of  the  appetite  and  functions  of  the 
stomach.  The  drug  was  exhibited  in  the  best  way, 
both  in  solution  and  pill,  and  in  many  cases  combined 
with  sulphur.  I have  seen  several  patients  who  had 
been  under  Mr  Clay’s  treatment,  but  they  were  in  no 
way  benefited  any  more  than  those  treated  by  myself, 
although  one  case  was  considered  by  Mr  Clay  to  be 
doing  very  well,  and  was  probably  reported  as  cured. 

When  cancerous  growths  approach  the  anus  con- 
siderable relief  may  be  obtained  by  dividing  the  sphinc- 
ter muscles ; defecation  is  thus  rendered  easier,  and 
no  possible  compression  can  be  exercised.  Usually, 
as  I have  said  when  speaking  of  stricture,  a cancer  of 
the  upper  part  of  the  rectum  paralyses  the  sphincters, 


278 


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doubtless  from  pressure  on  nerves,  and  the  patient  is 
not  able  to  retain  the  motions,  especially  if  they  are 
at  all  liquid.  When  diminution  of  the  calibre  of  the 
bowel  is  induced  by  cancer  near  the  anus,  Professor 
Yerneuil  has  proposed  free  division  of  the  gut  in  the 
dorsal  median  line,  or  even  the  excision  of  a segment 
of  the  posterior  wall  of  the  rectum.  The  former 
operation  I have  frequently  practised  ; the  latter  does 
not  commend  itself  to  my  mind. 

In  encephaloid  of  the  rectum  great  temporary  advan- 
tage and  much  relief  from  pain  may  be  obtained  by 
tearing  out  the  growth  by  the  fingers  or  a scoop  (as 
the  late  Professor  Simon  advocated  in  cancer  of  the 
uterus).  I prefer  my  fingers.  You  must  be  bold  in 
doing  this,  and  enucleate  the  whole  growth  quickly 
and  resolutely.  If  you  tear  away  only  superficial 
portions  hsemorrhage  may  occur  to  a considerable 
extent,  which  must  exhaust  your  patient,  and  no  real 
benefit  will  accrue. 

I had  a case  under  treatment  in  conjunction  with 
Mr  Pinching,  of  Gravesend,  in  the  person  of  a mem- 
ber of  our  own  profession.  An  immense  encephaloid 
growth  almost  filled  up  his  pelvis,  and  he  came  to 
London  to  see  if  I could  do  anything  for  him.  He 
was  in  such  a condition  that  I thought  he  could  not 
bear  colotomy,  but  I saw  that  if  I could  remove  the 
growth  in  great  part  without  his  losing  blood  to  any 
extent  great  relief  must  follow.  Accordingly,  assisted 
by  Mr  Pinching,  I made  a free  division  of  the  anus, 
the  muscles  and  fat  around  which  had  been  so  thinned 
away  by  the  pressure  of  the  growth  that  it  was  only 
like  cutting  through  thin  devitalised  skin.  Only  one 
small  vessel  appeared  inclined  to  bleed,  and  this  I 


CANCER  OF  THE  RECTUM 


279 


immediately  twisted.  I now  passed  my  hand  gently 
into  the  pelvis,  got  my  fingers  well  above  the  growth, 
and  tore  it  out.  A large  mass  was  at  once  removed. 
I then  continued  to  remove  all  I could  find,  and  it 
came  away  exactly  like  brain  in  appearance  and  in 
quantity  sufficient  to  fill  a good-sized  pudding-basin. 
I had  come  fully  prepared  with  subsulphate  of  iron, 
the  actual  cautery,  sponges,  and  wool,  in  order  to  be 
able  to  plug  at  once  should  haemorrhage  take  place, 
but  to  my  astonishment  there  was  no  bleeding  worth 
mentioning,  and  the  cavity  from  which  the  cancer 
had  been  removed  was  dry  and  grey  in  colour  with 
red  spots.  As  a precaution  against  secondary  haemor- 
rhage I put  in  sponges  powdered  with  the  subsul- 
phate of  iron,  but  there  was  no  bleeding  at  all. 
From  the  day  after  the  operation  the  patient  rallied, 
lost  his  night  sweats,  ate  and  drank  all  we  gave 
him,  and  was  able  to  return  home  in  a few  weeks. 
After  this  he  lived  in  comparative  comfort  for  two 
months,  then  as  the  growth  returned  he  very  gradually 
died  from  exhaustion,  nearly  five  months  having 
elapsed  since  he  underwent  my  treatment.  Twice 
since  this  I have  carried  out  this  plan  in  a similar 
manner,  and  in  both  cases  great  though  temporary 
relief  followed.  I do  not  see  why  it  should  not  be 
adopted  in  some  cases  of  epithelioma.  I was  surprised 
to  observe  in  the  three  cases  after  the  removal  of 
the  cancerous  growths  that  the  facial  appearance  of 
the  patients  so  immensely  improved ; in  fact,  they 
all  lost  the  malignant  aspect,  and  not  until  the  growth 
gradually  returned  and  with  it  the  poisoning  of  their 
blood  and  tissues,  did  the  countenance  reassume  its 
worn,  haggard  look.  So  also  in  respect  of  strength, 


280 


CANCER  OF  THE  RECTUM 


freedom  from  pain,  appetite,  and  capacity  for  sleep,  the 
change  for  the  better  was  remarkable.  In  this  variety 
of  cancer,  though  coJotomy  would  afford  in  some  degree 
relief  from  pain,  inasmuch  as  the  abundant  cancer  ele- 
ments are  still  present,  poisoning  of  the  general  system 
would  continue  in  full  force,  and  thus  extension  of  the 
term  of  life  is  not  to  be  obtained,  and,  indeed,  can  hardly 
be  anticipated  : in  such  cases  where  I have  performed 
colotomy  I have  found  the  patients  have  rapidly  suc- 
cumbed. 

Two  operations  have  been  practised  for  the  relief 
of  rectal  cancer.  The  one  is  extirpation  of  all  the 
diseased  portions  of  the  rectum,  which,  further,  is 
stated  by  some  surgeons  to  effect  a positive  cure  of 
the  disease  in  some  cases.  The  other  operation  is 
colotomy,  lumbar  or  inguinal,  which  only  professes  to 
relieve  pain,  and  possibly  extend  the  term  of  the 
patient’s  life. 

Extirpation  of  the  rectum  (as  it  is  frequently 
termed),  broadly  speaking,  may  be  undertaken  in  any 
form  of  cancer  which  does  not  necessitate  the  removal 
of  more  than  four  and  three  quarters  or  five  inches  of 
the  rectum  in  the  male  and  about  one  inch  less  in  the 
female.  Subject  to  the  results  of  increased  experience, 
I should  also  say  that  if  great  adhesions  are  formed  to 
the  sacrum  or  to  the  base  of  the  bladder  and  prostate 
gland,  or  to  the  neck  of  the  uterus  in  women,  the 
operation  is  probably  not  admissible,  and  certainly 
not  desirable.  Again,  if  any  enlarged  glands  exist  in 
the  inguinal  or  lumbar  regions  the  operation  cannot 
be  recommended;  lastly,  I should  say  the  patient 
ought  not  to  be  so  exhausted  as  to  render  it  doubtful 
whether  the  necessarily  rather  free  loss  of  blood 


CANCER  OF  THE  RECTUM 


281 


would,  to  a great  degree,  endanger  life.  The  length  of 
the  rectum  from  the  anus  which  may  be  removed  with- 
out opening  the  peritoneal  cavity  differs  in  individuals, 
and  the  conclusions  arrived  at  by  measurements  of  the 
dead  body  or  by  taking  plaster  casts  of  the  reflections 
of  the  peritoneum  are  fallacious,  and  must  be  taken  as 
an  approximation  to  the  truth  only.  In  a female 
patient  on  whom  I operated,  Douglas’  pouch  was  only 
two  inches  from  the  anus.  In  a male  fully  five  inches 
of  the  rectum  were  removed,  and  the  peritoneum  never 
seen ; and  in  another  male,  in  which  not  more  than 
three  and  a half  inches  were  cut  off,  the  peritoneum 
was  opened  and  a coil  of  intestine  protruded.  A point 
of  considerable  importance  in  operating  is  to  divide 
the  levator  ani  muscle  thoroughly  and  dissect  it  care- 
fully upwards,  by  which  means  you  get  the  rectum  to 
come  readily  down,  and  in  making  the  necessary  trac- 
tion on  it  you  do  not  draw  the  peritoneum  down  with 
it  Another  point  worth  remembering  is  that  the 
meso-rectum  is  more  developed  in  some  subjects  than 
in  others  and  descends  below  the  upper  half  of  the 
rectum.  Care  must  be  taken  in  using  the  knife  close 
to  the  sacrum,  as  you  may  easily  divide  the  trunk 
of  the  middle  hsemorrhoidal  artery,  when  severe 
bleeding  will  take  place,  and  difficulty  may  be  experi- 
enced in  arresting  it.  This  accident  has  occurred  to 
me,  but  I was  able  to  seize  the  vessel  and  secure  it 
quickly.  From  the  full  and  sudden  rush  of  blood, 
however,  I felt  convinced  that  a weak  patient  might 
readily  die  on  the  table.  It  is  not  my  intention  to 
enter  into  the  history  of  the  operation  of  excision  of 
the  rectum,  nor  shall  I describe  the  various  ways  in 
which  it  may  be  performed ; but  I beg  to  refer  the 


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reader  who  wishes  the  fullest  information  on  these 
subjects  to  the  able  and  exhaustive  work  of  Dr  Mar- 
chand,  entitled  £ Etude  sur  l’extirpation  de  l’extremite 
inferieure  du  Rectum.’  I will  only  here  mention  that 
Faget,  in  the  year  1739,  excised  the  rectum  for  cancer, 
that  after  this  the  operation  remained  in  abeyance  until 
1828,  when  it  was  revived  byLisfranc,  who  performed 
it  in  several  cases  with  success.  At  a comparatively 
recent  date  it  has  been  frequently  undertaken  by  both 
French  and  German  surgeons,  and  with  such  good  re- 
sults as  to  establish  the  operation  on  a reliable  basis. 
The  Americans  and  ourselves  have  brought  up  the  rear ; 
possibly  we  are  more  cautious  and  have  had  our  doubts 
as  to  the  great  benefits  claimed  for  it  by  our  foreign 
confreres  ; certainly  we  are  justified  in  distrusting  such 
statements  as  Dieffenbach’s,  who  says  that  he  had  had 
thirty  cases  of  successful  extirpation  of  the  rectum, 
the  patients  living  many  years  after  the  operation. 
We  have  also  felt  incredulous  as  to  the  advantage 
derived  from  cutting  out  the  rectum,  a portion  of  the 
urethra,  prostate  gland,  and  base  of  the  bladder,  as 
did  Nussbaum,  who  gravely  assures  us  that  the  patient 
recovered  all  his  functions  and  lived  for  three  years. 

My  own  experience  of  removing  cancerous  growths 
from  the  rectum  is  not  great.  I find  that  1 have 
excised  segments  of  the  bowel  by  knife  alone,  or  com- 
bined with  the  ecraseur  or  ligature  (elastic  and 
inelastic),  in  thirteen  cases,  and  in  sixteen  patients  I 
have  removed  the  rectum  in  its  whole  circumference,  the 
largest  portions  taken  away  being  in  two  cases  five 
inches  and  five  inches  and  a half  in  length  respectively. 

I shall  not  enlarge  on  my  operations  upon  segments 
of  the  rectum,  because  the  question  to  be  determined 


CANCER  OF  THE  RECTUM 


283 


is,  Can  one  cnre  a patient  who  has  cancer — say  epithe- 
lioma— by  excising  the  whole  of  the  diseased  portion 
of  the  rectum  ? 

Speaking  generally  of  partial  removals  of  the  cir- 
cumference of  the  bowel,  I must  say  I consider  the 
operation  unsatisfactory.  In  all  my  cases  which  I 
had  the  opportunity  of  observing  for  about  a year, 
either  a return  of  the  disease  took  place  in  the 
rectum,  or  the  glands  in  the  groin  became  affected, 
or  there  ensued  disease,  probably  cancer,  in  some 
internal  organ,  mostly  the  liver.  I find  seven  out  of 
my  thirteen  cases  died  within  eleven  months  of  the 
operation,  and  in  three  there  was  a return  of  the 
growth  in  the  rectum.  This  may,  of  course,  be 
attributed,  and  I think  rightly,  to  my  not  having 
totally  extirpated  the  local  disease ; but  in  four  cases 
the  disease  did  not  return  in  the  bowel  but  in  the 
glands.  One  of  my  patients  died  suddenly  two  days 
after  the  operation  from  syncope  on  getting  out  of 
bed.  Another  died  on  the  fourteenth  day  from 
erysipelas.  The  four  remaining  cases  recovered  from 
the  operation,  but  I have  no  knowledge  of  the  ultimate 
result.  In  one  case,  a patient  of  Mr  George  Ord,  the 
growth  did  not  return  until  after  one  year  and  five 
months  had  elapsed.  I had  therefore  arrived  at  the 
conclusion  that  partial  removal  of  the  rectum  was  an 
operation  which  could  not  be  very  strongly  recom- 
mended. Another  objectionable  feature  in  my  cases 
was  that,  contrary  to  the  experience  of  some  of  my 
professional  brethren,  the  patients  had  incontinence 
of  faeces  when  a large  portion  of  the  sphincters  was 
removed.  All  my  cases  were  not  epithelioma,  some 
presented  scirrhous  nodules,  as  in  the  case  I mentioned 


284 


CANCER  OF  THE  RECTUM 


where  the  growth  was  situated  over  the  prostate 
gland. 

Case  1. — My  first  excision  of  the  whole  circumference  of  the  rectum 
was  performed  at  St  Mark’s  Hospital  on  the  2nd  of  March,  1874.  The 
patient  was  a woman,  forty-seven  years  old,  who  was  sent  to  me  by  Dr 
Thomas.  She  was  a widow,  with  a family ; she  did  not  look  very 
unhealthy,  and  was  fairly  nourished,  but  she  said  she  had  become 
thinner.  Six  months  back  she  had  been  operated  on  in  the  London 
Hospital  for  fissure,  but  she  did  not  get  well ; soon  after  the  operation 
the  pain  was  as  bad  as  before  it.  There  was  constant  gnawing  pain  in 
the  anus,  much  increased  on  defsecation,  and  she  was  obliged  to  strain 
at  stool.  Examination. — The  anus  was  patulous,  but  just  inside  was  a 
contraction  formed  by  hardish  ulcerated  growths,  which  nearly  encircled 
the  bowel.  The  extent  upwards  was  not  more  than  an  inch.  There 
was  no  history  of  syphilis  nor  any  symptom.  I had  no  hesitation  in 
pronouncing  the  disease  to  be  epithelioma,  and  I removed  it  by  a 
circular  incision  around  the  anus  including  the  sphincter.  I dissected 
without  difficulty  the  bowel  up  as  there  were  no  adhesions,  drew  the  gut 
outside,  and  cut  it  off  with  scissors.  I took  care  to  have  the  bowel  held 
well  out  with  a vulsellum.  There  was  smart  bleeding,  but  four  vessels 
being  tied  it  all  ceased.  I then  joined  the  stump  of  the  rectum  to  the 
skin  with  six  wire  sutures.  On  the  day  after  the  operation  there  was 
much  swelling,  and  on  the  day  following  there  was  lividity  of  the  skin 
and  great  tension,  so  I was  compelled  to  remove  all  the  sutures,  and 
a quantity  of  pus  was  discharged  and  the  parts  widely  gaped.  I 
ordered  charcoal  poultices  and  injections  of  Condy’s  fluid.  After  a few 
days  the  wound  assumed  a healthy  appearance,  and  the  patient  made  a 
good  recovery.  I was  much  astonished  at  the  way  in  which  the  rectum 
gradually  grew  downwards  and  joined  the  skin,  forming  an  excellent 
cicatrix.  Before  leaving  the  hospital  she  had  some  power  over  her 
motions.  I watched  this  patient  for  sixteen  months,  following  her  to  a 
distance  rather  than  lose  sight  of  her.  No  disease  returned  in  the 
rectum,  but  in  eleven  months  she  had  abdominal  symptoms ; emacia- 
tion was  very  rapid ; she  suffered  much,  and  died  sixteen  months  after 
the  operation,  having  kept  her  bed  for  five  months. 

Case  2. — A man,  set.  36,  was  taken  into  St  Mark’s  Hospital,  and 
operated  upon  by  me  on  the  26th  of  October,  1874.  He  had  suffered 
from  hsemorrhoids,  and  had  been  under  my  care  fifteen  months  before. 
He  continued  well  until  three  months  ago,  when  he  began  to  suffer 
pain  in  the  rectum,  and  passed  blood  and  mucus ; the  bowels  were 
almost  always  relaxed  and  he  had  but  little  straining,  but  he  had 
incontinence  of  faeces.  The  patient  was  unhealthy  looking,  and  had 


CANCEE  OF  THE  EECTQM 


285 


lost  flesh  and  strength.  On  examination  a cancerous  growth  was  found 
encircling  three-fourths  of  the  ,rectum  on  its  dorsal  surface;  the 
anterior  portion  seemed  uninvaded,  nevertheless,  I thought  it  advisable 
to  remove  the  gut  in  its  entire  circumference  by  an  elliptical  incision. 
A silver  catheter  was  passed  into  the  bladder  to  steady  the  urethra. 
The  part  removed  was  about  two  inches  in  length  ; no  difficulty  pre- 
sented itself  in  the  operation.  I did  not  put  in  any  sutures,  but  filled 
the  wound  with  wool  soaked  in  weak  carbolised  oil.  No  bad  symptoms 
followed,  and  the  parts  were  quite  healed  in  four  weeks.  This  patient 
returned  to  me  three  months  after  the  operation  with  contraction  of  the 
anal  orifice.  I made  an  incision  to  correct  this,  and  he  had  no  trouble 
afterwards.  Seven  months  subsequent  to  the  operation  the  cancer 
appeared  higher  up  the  rectum  ; he  refused  any  further  surgical  inter- 
ference. After  a little  time  I losb  sight  of  him,  and  therefore  do  not 
know  how  long  he  survived.  For  four  months  after  the  operation  he 
was  quite  comfortable,  had  no  incontinence  of  faeces,  and  was  able  to  do 
his  work. 

Case  3. — A man,  in  rather  poor  circumstances,  but  who  would  not 
come  into  the  hospital,  was  sent  to  me  by  Mr  Slater,  of  Canonbury.  I 
saw  him  first  in  January  of  1875.  He  was  a spare  man,  about  fifty. 
He  had  suffered  pain  for  some  months  in  the  bowel ; it  was  pretty 
constant  and  much  aggravated  on  action  of  the  bowels.  He  felt  weak 
and  had  lost  much  weight.  On  examination  I found  a rather  large 
cancerous  growth  two  inches  from  the  anus ; it  did  not  involve  the 
whole  circumference  of  the  bowel ; it  was  movable  in  all  directions. 
I could  easily  reach  its  upper  border,  and  bring  the  growth  close 
to  the  anus.  I proposed  removing  it,  but  the  man  declined.  In 
March  following  he  came  to  me  again,  -saying  he  had  suffered  so  much 
that  I might  do  what  I liked  to  afford  him  relief.  Examination  showed 
that  the  cancer  had  approached  much  nearer  to  the  anus,  but  there 
still  remained  a zone  of  healthy  mucous  membrane  between  the  growth 
(which  I believed  to  be  epithelial)  and  the  anus.  There  did  not 
appear  to  be  any  important  adhesions  except  dorsally  ; anteriorly  very 
little  amiss  was  detected,  and  the  gut  was  quite  movable.  I deter- 
mined on  excising  the  growth,  and  to  leave  the  external  sphincter  by 
carrying  my  knife  around  the  bowel  in  the  space  between  the  two 
muscles.  I discovered  when  I had  made  this  incision,  from  which 
blood  flowed  plentifully,  that  I could  not  safely  remove  the  growth,  so 
I made  a deep  dorsal  cut  in  the  median  line  nearly  to  the  coccyx.  I 
was  delighted  to  find  the  amount  of  room  this  gave  me,  and  how  it 
rendered  the  operation  comparatively  easy.  In  all  my  subsequent 
cases  I have  commenced  my  operation  by  cutting  from  the  point  of  the 
coccyx  well  up  into  the  bowel,  a proceeding  so  strongly  recommended 


286 


CANCER  OF  THE  RECTUM 


by  Prof.  Yerneuil.  No  serious  obstacles  were  found,  and  I ablated 
about  three  inches  of  the  rectum  cutting  well  free  of  the  growth.  I 
attempted  to  bring  the  stump  of  the  rectum  to  the  skin  by  sutures,  as 
I hoped  thus  to  save  the  external  sphincter  which  I had  preserved,  but 
the  tension  was  too  great,  and  I,  therefore,  only  filled  the  wound  with 
sponges  soaked  in  a weak  solution  of  chloride  of  zinc.  The  after- 
progress on  the  whole  was  satisfactory  but  slow,  and  the  wound  took 
seven  weeks  in  healing.  This  patient  died  fourteen  months  after  the 
operation.  He  was  in  comparative  comfort  for  twelve  months,  and 
had  fair  command  over  his  motions,  unless  they  were  liquid.  The  dis- 
ease did  not  return  in  the  rectum,  but  the  glands  in  the  groin  became 
affected,  and  possibly  also  some  internal  organs.  He  suffered  much 
pain  towards  the  last. 

Case  4. — A gentleman,  set.  60,  came  to  me  from  the  country  saying 
he  was  suffering  from  stricture  of  the  rectum  which  had  troubled  him 
for  about  eight  or  nine  months ; he  had  consulted  several  eminent 
provincial  surgeons,  and  had  used  bougies  with  temporary  benefit.  He 
was  thin  but  fairly  strong  and  active ; the  expression  of  his  face  was 
healthy.  On  examination  I found  his  bowel  obstructed  by  a growth 
which  quite  surrounded  the  gut ; it  was  ulcerated  in  parts  ; it  com- 
menced about  an  inch  from  the  anus,  and  the  zone  measured  about  two 
inches  at  most  in  length ; it  was  freely  movable  in  all  directions ; no 
glandular  complication  could  be  detected.  I advised  its  immediate  re- 
moval. He  went  home  to  consider  the  matter,  to  consult  his  relatives, 
and  one  of  the  surgeons  he  had  seen.  He  returned  to  town  in  a few  weeks, 
and  I operated  upon  him  on  the  26th  of  January,  1876.  I operated 
exactly  as  in  the  last  case,  save  I made  the  dorsal  incision  the  prelimi- 
nary step.  In  this  case  the  bleeding  was  very  free,  and  I liberally  used 
the  actual  cautery  to  the  cut  surface  of  the  rectum  as  well  as  to  other 
parts.  The  wound  was  filled  with  sponges  steeped  in  a weak  solution 
of  carbolic  acid,  and  I introduced  a tube  into  the  rectum  in  order  that 
wind  might  escape,  the  retention  of  which  had  much  troubled  my  last 
patient.  The  wound  healed  kindly.  There  was  no  fever  after  the  first 
forty-eight  hours,  and  the  patient  suffered  remarkably  little.  In  five 
weeks  he  went  away  quite  satisfied,  and  I expected  a good  result ; but 
I was  disappointed,  as  in  five  months  he  came  to  me  with  a return  of 
the  growth,  quite  near  the  anus,  involving  the  scar  and  the  skin ; it 
was  a hard  lump  the  size  of  half  a walnut,  and  I advised  him  to  let  me 
cut  it  out ; he  acquiesced  and  I removed  it  freely,  but  did  not  take 
away  the  whole  circumference  of  the  gut.  This  I afterwards  regretted, 
as  I saw  him  in  about  three  months  again  with  much  more  growth  at 
the  anterior  part  of  the  rectum.  He  was  now  weak  and  greatly  broken 
in  health,  and  despairing  of  relief  he  refused  any  more  active  treat- 


CANCER  OF  THE  RECTUM  287 

ment.  I heard  from  his  friends  that  he  died  just  eleven  months  and  a 
half  from  the  first  operation. 

Case  5. — I saw  with  the  late  Dr  Daldy  a single  lady,  set.  40,  who 
was  affected  with  what  she  supposed  to  be  piles.  She  lost  blood  in 
small  quantities,  had  frequent  diarrhoea  with  incontinence  of  faeces,  and 
there  was  a discharge  of  sanious,  ill-smelling  mucus.  The  pain  was 
not  great  except  when  the  bowels  acted.  She  was  fairly  nourished, 
and  was  going  about  her  duties  as  usual.  On  examination  I found  a 
growth  in  the  rectum  one  and  a half  inches  from  the  anus,  and  extend- 
ing but  little  upwards ; it  was  hard  and  rough  to  the  touch  in  some 
parts  and  pulpy  in  others ; it  was  situated  principally  on  the  anterior 
part  of  the  bowel,  but  extended  laterally  nearly  to  the  sacrum  ; it  was 
most  adherent  to  the  vaginal  wall,  and  could  be  felt  distinctly  with 
the  finger  in  the  vagina,  but  I thought  it  did  not  involve  the  vaginal 
mucous  membrane.  With  some  misgiving  I advised  the  removal  of 
the  growth,  fearing  that  I should  have  to  take  out  a portion  of  the 
vagina  in  order  to  thoroughly  extirpate  it.  When  the  patient  found 
that  no  other  course  was  open  to  her  to  obtain  relief,  and  that  the 
danger  would  probably  be  increased  by  delay,  she  consented  to  have  the 
operation  done.  In  order  to  obtain  plenty  of  room  I commenced  with 
the  dorsal  median  incision,  and  made  an  exceedingly  careful  and 
cautious  dissection,  but  I found  the  growth  so  intimately  connected 
with  the  vaginal  wall  that  I was  compelled  to  remove  a portion  of  the 
vagina  fully  one  inch  in  length  by  half  an  inch  in  breadth.  The  hole 
made  being  elliptical,  after  having  removed  all  the  diseased  tissues,  I 
brought  the  edges  of  the  wound  together  with  four  iron  sutures.  I put  no 
dressing  in  the  wound,  simply  placing  a tube  in  the  bowel.  On  examining 
the  growth  there  could  be  no  doubt  that  it  was  mainly  epithelial,  but 
there  was  much  warty  structure  in  it  which  accounted  for  the  roughness 
I had  detected.  Fortunately  the  wound  in  the  vagina  healed  at  once, 
and  the  patient  made  an  excellent  recovery.  This  lady  I have  heard 
from  recently,  and  she  continues  quite  well  (three  years  after  the 
operation).  This  is  the  best  result  I have  as  yet  obtained,  but  it  is 
clear  that  the  growth  was  only  feebly  malignant. 

Case  6. — A man,  set.  61,  was  admitted  into  St  Mark’s  Hospital 
February,  1877,  suffering  from  epithelioma  of  the  rectum.  The  disease 
had  existed  about  three  months.  There  was  slight  obstruction  of  the 
bowel,  and  he  had  great  pain ; he  had  straining  at  stool,  and  there  was 
a constant  bloody  mucous  discharge ; he  had  no  incontinence  of  fseces 
unless  they  were  liquid ; he  was  a small,  spare  man,  of  not  unhealthy 
appearance  ; he  did  not  think  he  had  lost  flesh,  as  he  was  always  thin  ; 
he  had  always  enjoyed  good  health.  On  examination  a hard  growth 


288 


CANCER  OF  THE  RECTUM 


was  found  commencing  an  inch  from  the  anns ; it  encircled  the  bowel 
save  on  the  left  side  which  was  soft  and  ulcerated ; it  extended  about 
two  inches  upwards ; it  was  fairly  movable  except  towards  the  pros- 
tate. I operated  in  the  usual  manner,  save  that  I used  the  Paquelin 
cautery  more  freely  than  in  some  cases,  and  I severed  the  rectum, 
with  the  Paquelin,  inserting  a plug  into  the  bowel  to  cut  upon.  The 
gut  was  very  adherent  to  the  prostate  gland,  and  took  a considerable 
time  to  dissect  off ; the  capsule  of  the  prostate  was  removed,  and  the 
vesiculse  seminales  plainly  seen.  Rather  more  than  three  and  a half 
inches  were  removed.  I saved  the  internal  sphincter  muscle.  The  peri- 
toneum on  the  right  side  of  the  bowel  was  opened,  and  I saw  a coil  of 
intestine.  A sponge  well  carbolised  was  placed  against  the  opening, 
and  the  wound  was  filled  with  wool  soaked  in  carbolic  oil.  After  the 
operation  the  patient  had  not  a bad  symptom,  and  he  left  the  hospital 
quite  well,  having  gained  flesh  and  improved  in  appearance.  This  patient 
died  thirteen  months  after  the  operation.  No  return  of  the  disease 
took  place  in  the  rectum,  but  the  glands  in  the  inguinal  regions  were 
enormously  enlarged,  and  one  gland  was  the  seat  of  fungoid  ulceration. 

Case  7. — A man,  set.  50,  was  taken  into  St  Mark’s  Hospital  in 
March  of  1878,  and  came  under  my  care.  He  was  a tall,  thin  man  with 
a somewhat  haggard  countenance,  but  he  was  not  weak,  and  had 
worked  as  a carpenter  up  to  his  admission.  He  had  suffered  for  some 
months — he  could  not  say  exactly  how  many — from  trouble  in  the 
bowel,  the  common  symptoms  of  ulceration  or  malignant  disease  being 
present.  On  examination  I detected  an  epithelial  growth  in  the  rectum 
commencing  within  an  inch  and  a half  of  the  anus,  and  passing  up  so 
high  that  I could  only,  by  making  the  patient  stand  up  and  strain 
down,  just  feel  the  upper  border  of  the  cancer,  and  satisfy  myself  that 
I could  remove  the  whole  of  the  disease.  The  growth  was  more  than 
commonly  adherent,  especially  to  the  left  side.  A silver  catheter  was 
passed  into  the  bladder  when  I reached  the  anterior  part  of  the  rectum. 
I made  the  dorsal  incision,  and  carried  my  knife  around  in  the  inter- 
space between  the  sphincter  muscles.  The  dissection  was  very  difficult 
anteriorly  and  on  the  left  side,  and  I had  to  go  very  deeply  to  get  all 
the  growth  away.  I made  use  of  my  fingers  and  avoided  the  knife  as 
much  as  I could.  The  haemorrhage  was  free  throughout,  but  controll- 
able by  pressure.  Indeed,  not  a single  vessel  required  ligature  ; a few 
were  twisted.  In  separating  the  diseased- portion  of  gut  anteriorly  the 
prostate  gland  and  the  vesiculse  seminales  were  fully  exposed.  The 
stump  of  the  rectum  could  not  have  been  brought  down  to  join  the 
skin  if  I had  desired  to  bring  these  parts  together.  For  a few  days  the 
patient  was  in  a critical  condition,  the  temperature  keeping  at  104°  and 
a little  above,  but  these  symptoms  passed  off  with  the  establishment  of 


CANCER  OF  THE  RECTUM 


289 


suppuration  and  the  separation  of  some  largish  sloughs,  and  he  made  a 
good  though  rather  slow  recovery.  He  left  the  hospital  quite  well  with 
the  gut  grown  down  to  the  skin,  and  the  whole  part  as  smooth  and  soft 
as  healthy  mucous  membrane  could  be.  Eight  months  after  the 
operation  the  man  had  such  a contracted  orifice  to  the  bowel  that  I was 
compelled  to  take  him  into  the  hospital,  and  finding  that  bougies  were 
of  no  avail,  to  divide  the  anus  on  both  sides.  This  soon  cured  the  con- 
traction, but  I sent  him  out  with  a tube  to  prevent  any  recurrence 
of  the  trouble,  this,  however,  failed.  He  still  lives — more  than  three 
years  after  the  operation. 

Case  8. — A gentleman,  aet.  about  60,  was  sent  to  me  by  Dr  Wm,  Ord 
in  October,  187 6.  He  had  a nodule  of  hard  cancer  in  the  cellular  tissue 
jnst  inside  the  anus.  It  was  so  movable  and  circumscribed  that  I could 
not  resist  the  temptation  to  remove  it  by  a very  free  incision  without 
cutting  out  the  whole  circumference  of  the  bowel.  I was  confident  I 
had  got  away  all  the  diseased  tissue  recognisable  by  the  eye  or  touch. 
A microscopic  examination  showed  the  tumour  to  be  scirrhous.  From 
time  to  time  I saw  this  gentleman,  and  he  had  no  return  of  the  disease 
until  the  middle  of  March,  when  he  complained  of  discomfort  and  some 
pain  in  the  bowel.  He  had  been  quite  well  for  one  year  and  five  months. 
On  my  examining  him  I detected  small  nodules  in  the  mucous  men- 
brane  about  two  inches  from  the  anus.  The  site  of  the  old  excision  was 
quite  healthy.  I urged  him  to  allow  me  to  remove  the  nodules  at  once, 
but  .he  consulted  some  other  surgeons,  and  as  they  told  him  nothing 
could  be  done  as  the  places  were  too  high  up,  he  declined  to  allow  me 
to  interfere.  Some  months  elapsed  before  this  patient  came  to  me  again  ; 
finding  himself  getting  daily  worse  and  losing  strength  and  flesh  he  said 
he  was  prepared  to  submit  himself  to  my  wish,  but  on  examining  him  I 
found  the  disease  had  grown  down  nearly  to  the  anus,  and  was  almost 
all  round  the  bowel.  Under  these  circumstances  I said  that  Sir  James 
Paget  should  decide  whether  an  operation  should  be  done  or  not,  and 
as  Sir  James  decided  in  favour  of  an  operation,  I performed  it  in 
August,  removing  fully  four  inches  of  the  rectum.  The  growth  was  now 
clearly  epithelial,  in  fact,  it  was  an  admirable  specimen,  as  was  the  first 
tumour  I removed  a typical  example  of  scirrhus.  The  operation, 
in  consequence  of  the  adhesions,  was  a lengthy  one,  and  the  bleeding 
very  severe,  so  much  so  that  I used  the  Paquelin  cautery  more  than  I 
had  done  before.  The  peritoneum  was  not  injured.  A very  large 
chasm  was  left,  and  was  filled  with  sponges  soaked  in  a solution  of 
salicylic  acid.  Some  pressure  was  required  to  arrest  a general  oozing 
from  the  large  surface.  A tube  was  put  into  the  bowel.  The  night 
following  the  operation  the  patient  had  a most  severe  rigor,  and  the 
temperature  went  up  to  104-5°.  I thought  something  serious  was  about 
to  happen.  I took  out  all  the  sponges  and  syringed  the  parts  well  with 

19 


290 


CANCER  OF  THE  RECTUM 


solution  of  salicylic  acid,  and  administered  a large  dose  of  quinine.  In 
tlie  morning  the  patient  was  quite  comfortable,  with  the  temperature 
fallen  to  99  5°.  After  this,  although  the  patient  was  troubled  very 
much  by  two  or  three  actions  of  the  bowels  daily  which  we  could  not 
stop,  he  made  the  most  remarkable  recovery  I ever  saw.  Was  able  to 
return  into  the  country  fourteen  days  after  the  operation,  and  in  less 
than  four  weeks  the  whole  chasm  was  filled,  and  the  bowel  grown  quite 
down  to  the  orifice.  All  that  was  done  to  this  patient  was  to  wash  out 
the  wound  by  means  of  a syringe  after  the  action  of  the  bowels.  The 
parts  could  not  be  kept  sweet  or  clean,  as  a perpetual  oozing  of  faeces 
was  taking  place.  This  is  only  one  example  out  of  hundreds  I have 
had  that  satisfy  me  that  as  long  as  putrid,  filthy  matters  are  not 
retained,  shut  up,  in  a wound,  it  will  heal  well  and  rapidly,  indeed,  quite 
as  well  as  if  all  the  antiseptic  treatment  in  the  world  had  been  adopted. 
In  January,  1879, 1 found  this  patient  had  some  contraction  of  the  anal 
orifice.  As  bougies  did  not  seem  to  keep  it  well  open  I divided  one 
side  of  the  orifice  with  a knife,  and  by  keeping  a tube  in  for  a few  days 
all  got  well.  Curious  to  relate,  though  so  much  of  the  rectum  was  taken 
away,  it  grew  down,  and  a portion  of  mucous  membrane  protruded 
from  the  anus ; I thought  of  removing  it,  but  as  it  seemed  to  be  of  no 
consequence  I did  not  do  so.  This  patient  died  in  July,  1879 — having 
lived  nearly  three  years. 

Case  9. — In  December,  1878,  an  unmarried  lady,  set.  38,  came  to  me 
from  the  country.  She  looked  healthy  and  cheerful,  but  when  her  face 
was  in  repose  there  was  a sallowness  not  observable  when  she  was 
excited,  and  also  an  anxious  worn  expression.  She  at  once  told  me,  in 
the  most  matter  of  fact  way,  that  she  had  cancer  of  the  rectum,  that 
she  had  consulted  an  eminent  physician  in  the  country,  and  a still 
more  eminent  surgeon  in  London,  and  they  had  told  her  there  was 
nothing  for  her  but  to  endure  and  die.  Her  friends  confirmed 
her  statement.  The  patient  went  on  to  say  that  for  six  months 
her  suffering  had  been  very  great.  She  had  almost  constant  pain 
at  the  bottom  of  the  back,  of  a wearying,  sickening  character, 
and  the  paroxysms  at  and  after  defsecation  were  almost  more  than 
she  could  bear.  She  had  fought  against  this  and  concealed  it  as  much 
as  possible  from  her  friends,  but  her  life  was  really  unendurable.  On 
making  an  examination  an  epithelial  growth  in  the  rectum  was  patent 
enough.  It  commenced  about  an  inch  and  a half  from  the  anus,  the 
mucous  membrane  nearer  the  anus  being  quite  healthy.  There  was  no 
affection  whatever  of  the  external  parts.  The  zone  of  epithelial  growth 
was  about  an  inch  in  width,  and  it  involved  nearly  the  whole  circum- 
ference of  the  bowel.  My  finger  easily  reached  healthy  bowel  above  the 
growth.  There  were  no  enlarged  glands.  The  growth  was  readily 


CANCER  OF  THE  RECTUM 


291 


movable  in  all  directions  except  on.  the  right  side  of  the  vagina,  but  I 
did  not  think  this  would  render  an  operation  more  than  ordinarily  diffi- 
cult, indeed,  taking  the  whole  case  into  consideration,  I felt  that  it  was 
favorable  for  surgical  interference.  I expressed  this  opinion  to  the 
patient,  at  the  same  time  guarding  against  a too  sanguine  view  of  the 
case.  I recommended  that  the  opinion  of  some  eminent  authority 
should  be  taken  without  the  patient  saying  whom  she  had  previously 
seen.  The  gentleman  she  consulted  endorsed  my  opinion.  When, 
therefore,  proper  arrangements  had  been  made,  special  care  being 
taken  that  my  excitable  patient  should  have  nothing  to  worry  her,  I 
performed  the  operation.  The  adhesions  were  more  than  I expected, 
and  in  dissecting  away  the  growth  from  the  right  side  of  the  vagina 
the  peritoneum  in  Douglas’  space  was  opened,  and  a coil  of  intestine 
was  seen.  A carbolised  sponge  was  immediately  placed  against  the 
opening.  There  was  very  moderate  bleeding.  I used  Paquelin’s  cautery 
to  separate  the  diseased  portion  of  the  rectum,  where  I found  some 
large  vessels  existed,  the  rest  I cut  off  with  scissors.  The  operation 
took  just  forty-five  minutes  in  its  performance.  The  ether  had  been 
stopped,  and  the  patient  gave  evidence  of  recovery  from  the  anaesthetic 
by  moving,  but  when  placed  in  bed  she  was  found  to  be  still  insensible. 
After  a very  few  minutes  the  nurse  who  was  sitting  by  her  called  my 
attention  to  her  appearance,  and  I saw  that  she  was  very  pale  and 
slightly  blue  in  the  face.  The  breathing  had  ceased,  and  her  pulse 
could  not  be  felt.  Her  head  was  lowered  and  artificial  respiration  was  at 
once  commenced  by  my  friend,  the  late  Mr  Carr  Jackson,  and  was  con- 
tinued by  that  gentleman  and  myself  for  two  hours  and  a half.  During 
this  period  we  several  times  thought  she  was  dead,  as  immediately  the 
artificial  respiration  was  remitted  no  natural  breathing  took  place,  and 
the  heart  ceased  to  beat.  On  resuming  the  artificial  respiration  the  heart 
feebly  responded,  and  the  face  became  less  deadly  pale.  The  head  was 
all  the  time  kept  low,  and  my  battery  being  obtained  we  were  ready  to 
use  it  if  required.  Y ery  gradually,  to  our  great  relief,  natural  breathing 
commenced  (though  at  first  it  was  exceedingly  shallow),  and  the  pulse 
could  at  times  be  felt  at  the  wrist.  At  the  end  of  the  anxious  two  and 
a half  hours  the  breathing  was  fairly  restored,  and  the  heart  beat 
regularly  though  slowly  and  very  feebly.  At  10.30  the  operation  was 
concluded ; at  4.45  she  suddenly  awoke  to  consciousness,  and  was 
able  to  take  some  milk  with  egg  and  brandy.  After  this  she  rallied, 
but  at  11  p.m.  she  expressed  herself  as  feeling  very  exhausted,  and  was 
restless  and  thirsty.  Her  temperature  was  IOQ’50,  and  the  pulse  104. 
She  was  quite  warm  all  over,  her  mind  was  perfectly  clear,  and  she  was 
not  in  pain.  She  took  fluid  nourishment  freely.  On  the  following 
morning  1 found  she  had  slept  but  little  during  the  night,  was  restless, 
and  felt  general  malaise  with  great  thirst.  She  had  passed  a quantity 


292 


CANCER  OF  THE  RECTUM 


of  black  urine  like  a strong  infusion  of  black  tea;  the  pulse  was 
99,  and  tbe  temperature  barely  100°.  She  bad  taken  during  the 
night  plenty  of  fluid  nourishment,  Liebig’s  cold  soup,  milk  with 
egg  and  brandy.  There  was  no  sickness,  no  abdominal  tenderness, 
and  she  experienced  but  little  pain  in  the  wound.  She  was  troubled 
with  flatulence,  but  passed  wind  freely  from  the  bowel.  I removed  all 
the  sponges  from  the  wound,  it  looked  healthy  and  quite  sweet.  I 
replaced  a sponge  which  had  been  steeped  in  a solution  of  salicylic 
acid  against  the  spot  where  the  peritoneum  bad  been  wounded.  She 
was  not  exhausted  after  the  dressing.  During  the  day  she  improved, 
but  at  night  she  was  very  low,  more  restless,  but  not  in  pain.  She 
complained  of  a tightness  in  the  chest  and  occasional  spasmodic 
pains  in  the  left  side.  Auscultation  did  not  detect  anything  wrong 
with  the  lung.  She  was  still  flatulent,  but  wind  passed  in  both  direc- 
tions, and  there  was  no  distension  of  the  abdomen  nor  tenderness  on 
pressure.  She  had  taken  nourishment  fairly.  There  had  been  no 
vomiting.  The  temperature  was  100°,  and  the  pulse  94.  I was 
summoned  hastily  at  5 a.m.,  and  found  she  was  dead.  She  had  taken 
some  nourishment  a few  minutes  before  her  death  ; she  told  the  nurse 
she  felt  very  ill,  became  suddenly  pale,  and  died,  forty -three  hours  after 
the  operation.  An  examination  was  made  eleven  hours  after  death  by 
Mr  Jackson  and  myself.  All  the  organs  were  quite  sound.  There  was 
no  pneumonia  nor  pleurisy.  The  heart  was  small,  healthy,  and  contracted. 
There  was  not  a trace  of  lymph  or  peritonitis,  and  no  fluid  in  the  abdo- 
men. The  wound  in  Douglas’  space  was  firmly  united,  and  the  intes- 
tine lying  against  it  was  not  even  congested.  There  was  one  small 
patch  of  congestion  at  the  pyloric  end  of  the  stomach.  I was  very 
anxious  about  this  patient  from  the  first,  the  syncope  and  coma  were 
grave  matters,  and  she  never  thoroughly  rallied  after  the  operation. 
Syncope,  I presume,  was  the  immediate  cause  of  death. 

Case  10. — A patient,  set.  52,  was  sent  to  me  at  St  Mark’s  Hospital 
by  Dr  Evan  Evans ; he  had  been  more  or  less  ill  for  fifteen  months, 
and  believed  that  he  had  piles.  He  was  a tall,  thin  man,  with  an 
unhealthy  looking  face  ; he  had  lost  much  flesh,  and  was  not  very  strong. 
I saw  outside  the  anus  a ring  of  tabs  of  skin  discharging  ichorous  matter, 
and  inside  the  anus  several  large  internal  hsemorrhoids,  which  were  very 
vascular  and  came  readily  outside  when  he  strained.  From  the  piles 
an  epithelial  growth  extended  up  the  rectum  for  at  least  three  and  a 
half  inches.  It  was  adherent  to  the  prostate  gland  and  urethra  in 
front,  and  on  the  right  side  the  growth  extended  higher  up  than  on  the 
left,  but  I could  ascertain  the  whole  extent  of  the  disease,  and  saw  no 
insuperable  difficulties  to  its  removal.  Accordingly  on  the  13th  of 
January  I operated,  cutting  very  wide  of  the  anus  in  order  to  get  rid  of 


CANCER  OF  THE  RECTUM 


293 


the  external  flaps  of  skin,  and  also  to  avoid  wounding  the  hsemorrhoidal 
vessels  which  I knew  were  large.  The  dorsal  incision  owing  to  the 
piles  bled  unusually,  indeed,  throughout  the  operation  the  bleeding 
was  severe.  A silver  catheter  passed  into  the  bladder,  and  steadied  by 
Mr  Goodsall  aided  me  much  in  the  delicate  dissection  of  the  growth  from 
the  base  of  the  bladder  and  the  urethra.  The  parts  were  so  adherent 
on  the  right  side  that  I made  a wound  in  the  peritoneum,  but  no  coil 
of  intestine  came  through.  In  dissecting  the  growth  from  the  sacrum, 
where  also  it  was  more  firmly  adherent  than  I anticipated,  I came  on 
the  meso-rectum  and  wounded  the  middle  hsemorrhoidal  artery,  from 
which  the  rush  of  blood  was  so  great  that  had  I not  very  rapidly  seized 
it  the  patient  would  have  died  on  the  table.  The  house  surgeon  ad- 
ministering the  ether  was  immediately  aware  of  the  loss  of  blood,  as  the 
pulse  failed.  Rather  over  than  under  five  inches  of  bowel  were  removed. 
A carbolised  sponge  was  placed  against  the  spot  where  the  peritoneum 
was  wounded,  and  the  cavity,  which  was  very  large  (looking  as  if  the 
whole  interior  of  the  pelvis  had  been  scooped  out),  was  also  filled  with 
carbolised  sponges.  On  the  day  after  the  operation  the  patient  was 
doing  well,  had  passed  a fair  night,  taken  his  nourishment,  not 
vomited,  had  a tranquil  countenance,  and  was  cheerful.  The  abdomen 
was  soft  and  undistended ; there  was  no  pain  on  pressure  save  near  the 
right  iliac  region  which  was  rather  tender.  The  next  day  the  sponges 
were  removed,  and  the  wound  carefully  syringed  out  with  diluted 
Condy’s  fluid.  There  was  no  sloughing,  and  the  wound  looked  satis- 
factory. On  the  fourth  day  after  the  operation  he  was  attacked  with  a 
severe  rigor  followed  by  very  high  temperature  and  sweating;  sym- 
ptoms of  acute  peritonitis  set  in,  and  he  died  on  the  fifth  day.  A post- 
mortem showed  acute  peritonitis  all  over  the  abdomen.  Lymph  was 
found  between  all  the  coils  of  the  intestine,  and  a purulent  fluid  existed 
in  the  pelvis.  The  kidneys  were  not  quite  healthy.  The  patient  had 
no  serious  symptom  until  the  rigor,  indeed,  a few  hours  before  he  felt 
particularly  comfortable,  and  I thought,  on  the  whole,  well  of  him,  A 
trace  of  albumen  had  been  found  in  this  man’s  urine. 

Since  the  last  edition  of  this  work  was  published,  I 
have  excised  the  rectum  in  its  entire  circumference  in 
six  patients  only.  Four  operations  were  performed  in 
the  years  1879-80  and  two  during  the  present  year. 
The  paucity  of  recent  operations  is  due  to  a feeling  of 
dissatisfaction  on  my  part  with  the  results,  of  those  per- 
formed by  myself  and  of  those  I have  seen  done  by 
others.  Only  one,  I believe,  of  my  sixteen  cases  is  now 


294 


CANCER  OF  THE  RECTUM 


living;  lie  is  No.  7 of  the  series  related  in  full.  This 
patient  has  had  no  return  of  cancer,  but  he  is  in  the 
most  wretched  condition.  He  has  perpetual  incon- 
tinence of  faeces,  and  the  rectum,  for  three  inches  up- 
wards from  the  anus,  is  so  much  contracted,  that  unless 
he  constantly  wore  a tube  absolute  closure  would 
rapidly  take  place.  In  fact,  if  the  tube  be  left  out  all 
night,  great  difficulty  is  experienced  in  re-introducing 
it.  He  is,  as  a matter  of  course,  incapable  of  earning 
his  livelihood. 

The  method  of  operating  employed  by  me  is  that 
which  has  found  most  favour  with  the  French  authori- 
ties. The  deep  dorsal  incision  I really  consider  the 
ic  key”  to  the  operation.  It  gives  you  plenty  of  room, 
which  is  essential  if  you  have  to  remove  any  consider- 
able length  of  the  rectum,  and  so  get  fully  above  the 
growth.  Further,  it  saves  much  loss  of  blood,  as  it 
enables  you  to  secure  the  vessels  with  rapidity  and 
certainty.  Lastly,  it  forms  a deep  drain  or  channel 
through  which  all  obnoxious  matters  can  freely  escape. 
It  is  the  retention  of  morbific  particles  which  is 
dangerous ; let  them  all  run  away  as  they  are  gene- 
rated, and  you  may  defy  pyaemia  without  any  anti- 
septics. In  saying  this  I am  not  insensible  to  the 
advantages  of  these  chemicals  when  you  cannot  get 
deep  drainage. 

In  operating  on  the  male  I always  have  a silver 
catheter  passed  into  the  bladder ; the  assistant  hooks  it 
well  up  under  the  pubic  arch ; the  urethra  and  adjoin- 
ing parts  are  thus  steadied,  and  you  are  enabled  to 
carry  on  delicate  dissections  without  danger  in  the 
neighbourhood  of  the  trigone  of  the  bladder,  the 
prostate,  and  the  urethra.  After  the  operation  I think 


CANCER  OF  THE  RECTUM 


295 


it  very  advisable  to  place  a tube  in  the  rectum  to  favour 
the  escape  of  wind,  which,  if  retained,  will  cause  much 
discomfort  to  your  patient. 

In  women  the  assistant’s  finger  ought  to  be  intro- 
duced into  the  vagina  to  give  you  timely  warning 
when  you  approach  too  near  the  vaginal  mucous 
membrane.  In  most  of  my  cases  it  was  absolutely 
impossible  to  bring  down  the  stump  of  the  rectum  to 
the  skin ; if,  indeed,  these  parts  could  be  brought  to- 
gether the  tension  would  be  so  great  that  the  sutures 
would  be  torn  out  in  a few  hours.  I cannot  understand 
how  Yolkmann  brings  the  rectum  to  the  skin,  puts  in 
sutures,  and  gets  primary  union.  I can  only  say  that 
the  operation  I do  must  differ  much  from  Yolkmann’ s. 
I have  never  used  carbolic  dressings  with  the  view  of 
following  Mr  Lister  in  his  antiseptic  treatment;  in  fact, 
these  operations  appear  to  me  to  be  about  the  very  last 
to  which  the  process,  valuable  as  it  undoubtedly  is  in 
some  cases,  is  applicable.  Looking  at  the  chasm  I make 
and  the  part  in  which  it  is  made,  I should  say  that  shut- 
ting up  the  cavity  by  sutures  and  then  endeavouring 
to  keep  that  cavity  sweet  and  healthy  by  drainage  tubes 
and  deeper  tubes  put  through  holes  made  by  the  surgeon 
would  be  making  a plaything  of  antiseptic  surgery. 
How  can  you  prevent  faecal  matter  from  getting  into 
the  wound,  so  incompletely  closed  as  it  must  be  by 
sutures  ? Perhaps  it  may  be  said  that  the  bowels  must 
be  kept  confined  for  days  after  the  operation.  To  this 
I would  answer,  it  is  often  impossible  to  do  so.  The 
intestines  of  these  patients  are  always  in  an  irritable 
condition,  and  neither  opium  nor  any  other  drug  will 
delay  action  for  long.  Then,  again,  I would  say  it  is 
not  good  to  confine  the  bowels,  for  should  a large  mass 


296 


CANCER  OF  THE  RECTUM 


form  in  the  upper  part  of  the  rectum,  such  pressure  on 
the  vessels  is  exercised  that  congestion  and  stasis  are 
induced,  and  these  conditions  are  quite  inimical  to  the 
healing  process.  I am  fully  convinced  that  the  best 
after-treatment  of  these  cases  is  to  establish  a good 
drainage  from  the  wound,  to  keep  the  parts  clean  by 
syringing  with  some  innocent  disinfectant,  and  if  you 
accomplish  this  you  need  not  fear;  the  wound  will 
rapidly  fill  up,  and  the  rectum  will  grow  downwards 
and  unite  with  the  skin. 

My  cases  are  only  sixteen  in  number.  I will  not, 
therefore,  draw  definite  conclusions  from  them,  save 
that  the  operation  may  be  accomplished  even  when  the 
growths  are  very  considerable  and  the  adhesions  even 
abundant ; at  the  same  time,  I would  point  out  that 
there  are  dangers  connected  with  the  operation  not  to 
be  despised,  but  which  increased  knowledge  may 
enable  us  more  surely  to  overcome.  I would  also 
observe  there  is  a tendency  to  look  too  lightly  on  the 
danger  of  opening  the  peritoneum.  In  three  of  my 
cases  that  cavity  was  opened,  and  in  two  no  evil 
resulted,  but  in  the  third,  I have  no  doubt,  it  was  the 
cause  of  death.  An  important  question  is,  Do  we 
really  obtain  a cure  in  cases  of  epithelioma  ? My 
modest  experience  would  lead  me  to  think  that  such  a 
result  is  very  uncommon,  and  must  not  usually  be 
expected.  A second  question,  Do  we  obtain  much 
prolongation  of  life  by  the  operation  ? I am  inclined 
to  the  opinion  that  this  question  cannot  be  positively 
answered  in  the  affirmative.  Epithelioma  in  many 
cases  advances  very  slowly  ; I have  had  a considerable 
number  of  patients  who  have  lived  four  years  and  up- 
wards from  the  first  appearance  of  the  symptoms,  no 


CANCER  OF  THE  RECTUM 


297 


operation  having  been  undertaken.  If  the  disease  be 
near  the  anus,  not  extending  say  more  than  two  inches 
up  the  bowel,  I should  not  hesitate  to  excise  it.  In 
the  large  majority  of  cases,  however,  the  disease  com- 
mences at  more  than  two  inches  from  the  anus,  and 
extends  for  two  or  three  inches  higher  up.  These 
cases  almost  always  do  badly,  and  it  therefore  follows 
that  the  number  of  patients  who  can  be  benefited  by 
excision  of  the  disease  is  comparatively  small.  Mr 
Rouse,  of  St  George’s  Hospital,  has  related  a case  in 
the  6 Lancet,’  October  2nd,  1880,  of  removal  of  a small 
cancerous  growth  of  the  rectum,  about  an  inch  from 
the  anus,  by  making  a curved  incision  just  outside 
the  external  sphincter,  and  pushing  the  growth  from 
the  rectum  through  this  opening ; it  was  then  cut  off, 
and  the  patient  did  well.  Mr  John  Gay  has  related 
an  almost  exactly  similar  case,  but  it  is  obvious  that  the 
feasibility  of  the  operation  depends  upon  the  extremely 
rare  circumstance  of  the  growth  being  so  low  down. 
Mr  Gay’s  patient,  I know,  did  not  long  survive  the 
operation,  but  I do  not  know  how  Mr  Rouse’s  case  has 
terminated.  Mr  James  Adams,  of  the  London  Hospital, 
has  suggested  that,  prior  to  excising  cancer  of  the 
rectum,  colotomy  should  be  performed.  His  argu- 
ments in  favour  of  such  a step  are  briefly  as  follows  : — 
“ That  in  cases  of  any  but  of  the  slightest  degree,  the 
operation  might  prove  incomplete  and  the  disease 
speedily  return  ; that  after  complete  removal  of  the 
lower  part  of  the  rectum,  the  subsequent  contraction 
is  often  very  great,  and  sometimes  quite  intractable ; 
and  that  in  any  case  the  healing  of  the  wound  would 
be  expedited  and  the  tendency  to  local  recurrence 
diminished  by  diverting  the  course  of  the  fseces.”  The 


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CANOER  OF  THE  RECTUM 


author  had  recently  operated  in  a case  in  which  this 
line  of  action  had  been  adopted  with  the  most  satis- 
factory result.  I am  inclined  to  think  that  some, 
at  all  events,  of  the  published  cures  were  not  really 
cases  of  cancer,  but  lupoid  or  other  ulcerations. 
Probably  a careful  microscopic  examination  of  the 
removed  growth  would  be  the  only  means  of  de- 
ciding the  question.  The  excision  of  epithelioma 
usually  at  once  relieves  the  patient  of  great  pain, 
and  much  comfort  is  obtained.  As  to  there  being 
a new  sphincter  muscle  formed  around  the  cut  end 
of  the  rectum  I do  not  believe  this  ever  occurs ; 
there  may  be  some  power  of  retaining  faecal  matter 
when  not  liquid,  but  that  only  arises  from  there 
always  being  a certain  amount  of  contraction,  and  from 
the  fact  that  the  anal  opening  usually  leads  into  a large 
cavity,  where  faeces  can  rest  for  a time  until  expulsive 
exertions  are  made.  This  contraction  is  often  so  con- 
siderable as  to  become  an  obstacle  to  the  passage  of  the 
excretions,  and  then,  as  in  three  of  my  cases,  divisions 
may  be  called  for,  together  with  the  more  or  less  con- 
tinuous use  of  tubes.  Finally,  is  the  operation  one  to 
be  undertaken  in  all  cases  heedless  of  the  extent  of  the 
disease,  the  parts  involved,  or  the  age  and  condition 
of  the  patient,  as  some  German  surgeons  practically 
assert  ? I say  by  no  means.  The  cases  must  be  care- 
fully selected  if  any  lasting  success  is  to  be  obtained. 

The  operation  of  excision  of  the  rectum  and  its 
results  have  been  compared  by  some  surgeons  with 
colotomy,  when  really  there  is  no  ground  for  com- 
parison ; both  operations  may  be  equally  advan- 
tageous in  fit  cases,  but  they  cannot  be  substituted 
the  one  for  the  other ; the  most  enthusiastic  advocate 


COLOTOMY  IN  CANCER  OF  THE  RECTUM 


299 


of  colotomy  would  scarcely  think  of  operating  on  the 
cases  best  fitted  for  excision,  and  the  converse  also 
obtains. 

I shall  now  proceed  briefly  to  consider  the  subject  of 
colotomy.  This  operation  may  be  done  in  the  inguinal 
or  lumbar  regions,  either  right  or  left.  Inguinal  colo- 
tomy I have  never  performed,  except  in  infants,  and  I 
have  experience  of  two  such  cases  only,  neither  of 
which  was  very  successful.  The  left  lumbar  region 
for  anatomical  reasons  is  the  best  suited  to  colotomy, 
but  should  the  obstruction  be  high  up  the  bowel  the 
right  side  may  be  resorted  to.  I have  now  thirty-nine 
times  performed  colotomy  for  the  relief  of  patients 
suffering  from  cancer , and  twenty-five  times  in  cases 
of  non-malignant  disease,  sixty-four  cases  in  all.  I do 
not  see  the  necessity  (the  advantages  of  this  operation 
being  quite  established)  of  relating  my  cases  in  detail. 
Most  of  them  have  at  various  times  been  published  in 
hospital  reports  or  the  medical  journals. 

Generally,  I will  say  that  colotomy  is  justifiable 
when  an  obstruction  existing  in  the  lower  bowel 
threatens  a patient’s  life,  also  when  an  opening  has 
taken  place  between  the  rectum  and  bladder,  or 
urethra,  or  even  vagina  high  up,  the  distress  in  these 
cases  being  exceedingly  great.  (I  have  recently  had 
the  care  of  a woman , into  whose  bladder,  by  some 
devious  route,  a cancer  of  the  rectum  ulcerated,  and 
she  passed  faeces  and  wind  per  urethram.) 

When  a cancer  of  the  rectum  is  rapidly  advancing, 
and  great  pain  exists  which  ordinary  means  cannot 
alleviate,  then  colotomy  may  be  done ; but  I do  not 
think  colotomy  advisable  or  justifiable  simply  because 
cancer  of  the  rectum  exists ; and  my  large  experience 


300 


COLOTOMY  IN  CANCER  OF  THE  RECTUM 


teaches  me  that  the  idea  of  prolonging  life  by  a very 
early  operation  is  erroneous  and  not  borne  out  by 
facts.  When  I say  my  large  experience  I do  not  speak 
of  my  own  operations  alone,  but  of  all  those  I have 
seen  others  perform,  and  of  which  I know  the  ultimate 
result.  I admit  that  when  obstruction  exists  a patient 
may  be  snatched  from  immediate  death  by  the  operation, 
but  that  is  not  the  question.  I mean  can  we  say  to 
every  patient  seen  in  the  early  stage  of  cancer, — “ If 
you  will  submit  to  colotomy  you  will  live  much  longer 
than  if  you  do  not  ?”  I aver  that  we  cannot  truth- 
fully say  this,  and  I believe  my  position  proven  by  the 
natural  history  of  the  disease  to  which  I shall  directly 
refer. 

Of  my  thirty-nine  cases  of  colotomy  in  cancer  the 
best  result  was  obtained  in  a man  with  a scirrhous 
growth  filling  up  the  pelvis,  who  lived  four  and  a half 
years  after  the  operation.  My  second  in  a woman,  who 
lived  nineteen  months,  and  was  for  twelve  months  in 
wonderful  comfort.  Only  five  of  my  patients  have  died 
within  fourteen  days  of  the  operation.  Two  patients 
succumbed  from  phlegmonous  erysipelas.  In  another 
case  the  operation  was  done  when  the  patient  was 
almost  “ in  articulo  mortis,”  and  death  took  place  in 
ten  days  from  exhaustion,  but  the  relief  to  pain  was 
so  great  that  no  regrets  were  felt  by  the  surgeon,  the 
patient,  or  the  friends.  In  the  fourth  the  patient,  a 
lady,  died  within  nine  days  of  the  operation  ; there 
was  entire  obstruction  of  the  bowel  and  anasarca; 
surgical  aid  was  delayed  too  long ; immediately  after 
the  colotomy  paracentesis  abdominis  was  performed. 
Acute  pleurisy  was  the  immediate  cause  of  death. 

In  a man,  set.  39,  with  cancer  of  the  rectum,  of 


COLOTOMY  IN  CANCER  OF  THE  RECTUM 


301 


epithelial  character,  I operated  comparatively  early. 
There  was  no  obstruction,  no  emaciation,  no  detectible 
glandular  affection,  but  he  suffered  great  pain.  The 
disease,  or  rather  the  symptoms,  I will  say,  had  existed 
only  for  four  months.  The  patient  recovered  from 
the  operation  exceedingly  well,  and  lived  fifteen  months 
after  it,  dying  from  extension  of  the  disease,  general 
blood  poisoning,  and  enlarged  lumbar  glands.  This 
patient  may  fairly  be  said  to  have  died  about  twenty 
months  from  the  commencement  of  the  disease. 

My  observations  on  the  natural  history  of  cancer  in 
all  forms  lead  me  to  conclude  that  the  large  majority 
of  victims  will  die,  i.  e.  the  disease  will  run  its  course, 
in  about  two  years.  In  the  case  I last  mentioned  pain 
was  mitigated  and  accidents  avoided,  but  I could  not 
say  that  life  was  prolonged.  I do  not  consider  aver- 
ages in  surgical  statistics  of  any  great  utility,  but  I 
may  mention  that  the  average  length  of  life  after  ope- 
ration in  my  thirty-nine  cases  of  cancer  was  six 
months  and  two  weeks.  However  interesting  this 
part  of  my  subject  may  be,  I have  neither  time  nor 
space  to  pursue  it  further,  but  shall  turn  to  the 
operation  itself. 

The  method  of  opening  the  colon  now  generally 
adopted  is  known  as  Amussat’s,  and  was  advocated  by 
that  surgeon  in  his  treatise  published  in  1839  “ On  the 
Possibility  of  Establishing  an  Artificial  Anus  in  the 
Lumbar  Region.”  In  the  adult  I think  there  can  be 
no  doubt  that  Amussat’s  is  the  best  procedure. 

By  attention  to  certain  rules  lumbar  colotomy  will 
not  be  found  very  difficult,  but  the  not  infrequent 
occurrence  of  misadventures  induces  in  my  mind  the 
belief  that  many  surgeons  are  not  yet  sufficiently  alive 


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to  the  necessity  for  considerable  precision  in  the  per- 
formance of  this  operation,  more  especially  when  the 
bowel  is  undistended. 

The  directions  usually  afforded  in  works  on  sur- 
gery lack  the  element  of  precision,  which  I think 
indispensable.  The  error  usually  made  in  operating  is 
to  search  for  the  colon  too  far  from  the  spine ; the 
result  of  this  is,  that  the  peritoneum  is  inadvertently 
opened,  a coil  of  small  intestine  at  once  shoots  up 
into  the  wound ; this  misleads  the  surgeon  and  renders 
the  discovery  of  the  colon  more  difficult  as  well  as  the 
operation  more  likely  to  prove  fatal. 

The  anatomical  guide  to  the  position  of  the  ascend- 
ing or  descending  colon  is  the  free  edge  of  the 
quadratus  lumborum  muscle,  but  this  is  by  no  means 
always  easily  found,  and  consequently  it  is  better  to 
substitute  a more  certain  and  unmistakeable  guide, 
and  this,  as  I have  stated  in  my  article  on  colotomy  in 
the  “ St  Thomas’s  Hospital  Reports”  for  1870,  may  be 
obtained  by  marking  a spot  on  the  crest  of  the  ilium, 
fully  half  an  inch  posterior  to  a point  midway  between 
the  two  superior  spinous  processes. 

From  more  than  fifty  dissections  and  the  experience 
of  over  eighty  operations  of  my  own  and  others,  I can 
confidently  assert  that  the  colon  is  always,  normally, 
situated  opposite  this  point. 

Before  operating  I mark  this  spot  on  the  crest  of 
the  ilium  with  ink  or  iodine  paint,  and  I have  always 
found  it,  when  the  superficial  tissues  are  divided,  a 
most  useful  landmark  and  guide  to  the  exact  position 
of  the  intestine.  This  is  especially  valuable  if  you 
fail  to  recognise  the  deeper  structures  as  they  are 
incised,  which  you  may  easily  do  if  the  patient  be 


COLOTOMY  IN  CANCER  OF  THE  RECTUM 


303 


muscular  or  fat.  On  the  whole  I prefer  the  oblique 
incision,  as  recommended  by  Mr  Bryant,  downwards 
from  the  last  rib  towards  the  anterior  superior  spinous 
process  of  the  ilium,  and  the  centre  of  this  cut,  which 
should  be  made  from  three  to  four  inches  in  length,  must 
be  opposite  your  mark  upon  the  crest.  When  the  intes- 
tine is  at  all  distended  I make  my  incision  not  more 
than  two  inches  in  length,  and  I find  this  quite 
sufficient. 

When  about  to  operate  the  patient  should  be  placed 
upon  a hard  couch  in  the  prone  position,  with  a slight 
inclination  towards  the  right  side,  and  a hard  pillow  is 
to  be  adjusted  under  the  left  side,  so  as  to  render  the 
loin  tense  and  prominent. 

I have  frequently  seen  the  operator  stand  behind 
the  patient.  I prefer  standing  in  front,  in  which 
position  I think  you  are  less  likely  to  make  your 
deeper  incisions  too  far  forward,  and  so  inadvertently 
open  the  peritoneum. 

The  structures  should  be  very  carefully  divided  on  a 
director,  and  this  should  be  done  slowly  and  de- 
liberately, waiting  until  bleeding  be  arrested,  so  that 
the  anatomical  relation  of  the  parts  be  duly  recog- 
nised as  the  operation  proceeds.  I think  it  very 
desirable,  though  not  absolutely  necessary,  that  the 
fascia  lumborum  should  be  thoroughly  made  out,  and 
if  possible  the  edge  of  the  quadratus  lumborum  muscle 
clearly  exposed.  If  this  is  seen  a blunt-pointed  bis- 
toury should  be  passed  beneath  it  and  the  muscle 
freely  divided  ; when  this  is  done  the  colon  will  be 
found ; it  is  generally  covered  by  fat,  which  may  be 
mistaken  for  the  gut,  but  this  error  will  be  soon 
discovered  and  is  very  easily  rectified.  It  is  of  the 


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COLOTOMY  IN  CANCER  OF  THE  RECTUM 


•utmost  importance  that  the  deeper  incisions  be  kept 
the  same  length  as  the  cut  through  the  skin.  If  you 
do  not  attend  to  this  rule,  by  the  time  you  reach  the 
lumbar  fascia  you  will  be  working  in  a deep  triangular 
hole,  the  apex  of  wdiich  is  furthest  from  you ; and  it 
will  be  almost  impossible  to  find  the  gut,  even  if  you, 
have  come  down  upon  the  right  spot.  From  personal 
experience,  and  the  many  operations  I have  seen 
performed  by  other  surgeons,  I am  quite  convinced 
that  this  is  the  secret  of  overcoming  the  difficulties  of 
the  operation.  If  the  colon  be  fairly  exposed  as  I 
have  directed,  there  is  usually  but  little  difficulty  in 
recognising  it,  even  when  it  is  quite  undistended,  and 
picking  it  up  from  the  bottom  of  the  wound.  In  most 
of  my  cases  one  of  the  longitudinal  bands  was  clearly 
observed,  and  in  others  hard  portions  of  faeces  could 
be  felt  before  the  gut  was  opened. 

The  intestine  having  been  found,  it  should  be  drawn 
well  out  of  the  wound,  and  opened  longitudinally  for 
about  an  inch,  the  edges  of  the  incision  being  stitched 
to  the  edges  of  the  skin.  The  sutures  should  be 
passed  through  the  colon  before  opening  it,  to  avoid 
any  chance  of  the  contents  running  into  the  wound. 
I have  found  thick  silk  sutures  answer  better  than 
wire,  as  they  do  not  so  easily  cut  their  way  out,  and  I 
retain  them  until  I observe  that  they  have  begun  to 
ulcerate  through  the  skin;  but  it  is  better  not  to 
keep  them  in  too  long — forty-eight  hours  is  usually 
sufficient. 

The  immediate  fatality  of  the  operation  depends 
almost  wholly  upon  whether  any  faecal  matter  or  mor- 
bific fluid  runs  into  the  peritoneal  cavity ; therefore  it 
should  be  remembered  that  it  is  desirable  to  approach 


COLOTOMY  IN  CANCER  OF  THE  RECTUM 


305 


and  open  the  colon  on  its  dorsal  or  even  spinal  aspect 
rather  than  upon  its  outer  side,  and  to  avoid,  by  all 
means  in  your  power,  opening  the  peritoneum. 

When  the  intestine  is  collapsed  I have  recommended 
a quantity  of  fluid  to  be  injected,  but  I must  now 
qualify  that  advice,  and  say  it  is  better  to  endeavour 
to  distend  the  gut  with  air  if  you  cannot  find  it 
without. 

If  the  case  goes  on  fairly  well  the  after-treatment  is 
generally  very  simple.  I usually  apply  a weak  solu- 
tion of  carbolic  acid  or  Condy’s  fluid  to  keep  the  part 
from  getting  dry  and  stiff  and  to  deodorize,  as  the 
smell  is  sometimes  very  unpleasant.  A charcoal  poul- 
tice is  often  very  advantageous. 

When  the  bowels  have  been  long  confined  before  the 
operation,  they  are  occasionally  very  difficult  to  get  to 
act,  and  you  may  have  to  employ  a scoop  to  remove 
the  indurated  fecal  lumps ; this  being  accomplished, 
enemata  may  be  used  to  stimulate  the  colon  to  action, 
and  relief  will  be  obtained. 

The  patient  is,  as  a rule,  able  to  get  about  in  four 
weeks  from  the  time  of  the  operation. 

When  up  they  may  wear  a well-fitting  india-rubber 
pad  to  prevent  the  escape  of  wind  and  motion.  I now 
have  the  pad  made  a little  hollow  and  fill  the  concavity 
with  cotton  wool,  which  will  absorb  any  slight  moisture 
and  keep  the  part  dry.  Some  of  my  patients  preferred 
merely  a pad  of  wool  and  a napkin  over  it,  to  any 
mechanical  appliance.  It  is  a great  thing  to  cultivate 
the  habit  of  getting  the  bowels  to  act  the  first  thing  in 
the  morning ; by  this,  incontinence  and  trouble  during 
the  day  are  best  avoided. 

I always  recommend  the  use  of  plenty  of  cold  water 

20 


306 


COLOTOMY  IN  CANCER  OF  THE  RECTUM 


night  and  morning  to  the  lumbar  aperture ; by  which 
means  the  mucous  membrane  may  be  kept  healthy  and 
the  probability  of  protrusion  of  the  gut  be  lessened. 
This,  however,  if  the  patient  should  survive  the  opera- 
tion for  many  months,  is  certain  to  occur  to  a greater 
or  less  extent ; generally  it  can  be  returned  by  gentle 
pressure,  but  sometimes  it  can  be  replaced  only  by 
passing  a softened  bougie  or  thick  tallow  candle  and 
carrying  the  bowel  upwards. 

Since  I have  made  a much  smaller  external  incision 
I have  not  found  the  protrusion,  as  a rule,  so  trouble- 
some, but  still  it  will  occur. 

Among  the  most  distressing  symptoms  attending 
cancer  of  the  rectum  must  be  numbered  violent 
straining.  I had  anticipated  that  colotomy  would 
entirely  remove  this  cause  of  suffering,  but  thao 
is  by  no  means  the  case.  The  cancerous  growth, 
especially  when  it  approaches  the  anus,  provokes 
reflex  action,  and  irresistible  bearing-down  results ; 
this  also  is  the  case  when  fascal  matter  passes  the 
opening  in  the  loin  and  accumulates  in  the  bowel  below. 
This  was  supposed  to  be  almost  an  impossibility,  but 
in  my  experience  it  is  of  frequent  occurrence,  and 
causes  severe  pain  as  well  as  straining.  In  a case  I 
had  with  Mr.  Aikin  it  was  one  of  the  evils  we  had 
always  to  combat,  and  it  rendered  syringing  out  the 
rectum  from  the  anus  a matter  of  daily  necessity,  and 
added  much  to  the  patient’s  suffering.  In  such  con- 
ditions the  treatment  must  consist  in  keeping  the  rec- 
tum as  clear  of  motion  as  possible  by  frequent  washing 
out  with  warm  water  and  some  disinfectant,  the  par- 
ticular one  used  being  changed  from  time  to  time.  I 
think,  on  the  whole,  carbolic  acid  is  the  worst  you  can 


COLOTOMY  IN  CANCER  OF  THE  RECTUM 


307 


employ,  as  even  when  extremely  weak,  it  is  liable  to 
set  up  irritation  in  the  cancerous  growth  in  the  bowel 
and  a consequent  increase  of  local  pain.  Salicylic  acid 
and  thymol  I find  good,  but  on  the  whole  I prefer  a 
solution  of  permanganate  of  potash,  which  is  soothing 
to  the  part  and  readily  destroys  odour,  and  has  no 
unpleasant  attributes  in  itself.  Surgeons  are  too  apt  to 
forget  that  when  colotomy  is  performed  the  cancer  is 
still  left  in  the  bowel,  and  attention  must  be  directed 
to  this.  The  discharge  must  be  removed  by  careful 
syringing,  and  great  relief  may  be  given  to  the  patient 
by  injections  of  watery  solutions  of  opium,  and  other 
sedatives  per  anum.  The  patients  should  live  well, 
and  I always  order  as  much  cod -liver  oil  as  they  can 
take  without  disturbing  the  stomach. 


CHAPTER  XIX 


EODENT  OE  LUPOID  ULCEE 

Although  some  of  my  critics  have  taken  exception 
to  the  word  “ rodent/5  I cannot  on  reconsideration  find 
a more  appropriate  appellation  unless  it  be  “ lupoid,55 
but  I think  the  term  is  not  so  very  important.  What 
I wish  to  do  is  to  describe  and  define  a species  of  ulcer 
of  the  rectum  not  often  met  with,  which  is  totally 
distinct  from  simple  ulcer,  and  in  my  opinion  is  very 
nearly  allied  to  epithelial  cancer,  although  it  differs 
from  that  malady  in  several  essential  particulars  which 
I will  presently  detail. 

In  its  early  stage  the  ulcer  is  very  difficult  to  distin- 
guish from  a syphilitic  sore,  and  when  it  is  situated 
just  within  the  sphincter  it  may  also  readily  be  mistaken 
for  the  ordinary  painful  rectal  ulcer.  Rodent  ulcer  in 
the  rectum  differs  from  the  malady  of  the  same  name 
found  on  the  face,  in  being  as  a rule  most  terribly 
painful,  and  in  having  no  indurated  margin ; it  also 
differs  in  another  essential  and  important  point, — it  is 
very  much  less  curable ; as  far  as  I know,  it  is  nearly  as 
deadly  as  cancer,  though  not  so  rapid  in  its  progress. 
I cannot  say  that  I ever  saw  a case  of  undoubted 
rodent  ulcer  of  the  rectum  cured,  but  I have  now  a 
case  which  has  remained  well,  after  excision,  for  more 
than  four  years. 


RODENT  OR  LUPOID  ULCER 


309 


It  is  a happy  thing  that  the  disease  is  an  uncommon 
one ; in  my  own  practice  I have  had  only  nine  decided 
cases,  and  I do  not  remember  to  have  seen  more  than 
fourteen  in  all. 

Rodent  or  lupoid  ulcer  may  be  distinguished  from 
epithelioma  by  the  following  peculiarities  : — It  does  not 
invade  neighbouring  organs  by  infiltration,  nor  does 
it  contaminate  through  the  lymphatics ; as  far  as  I 
know,  it  never  forms  secondary  deposits,  and  it  pro- 
duces no  hardness.  It  is  not,  I am  informed  by 
microscopists,  a disease  of  the  follicles  of  the  rectum. 

It  differs  from  secondary  or  tertiary  syphilitic  ulcer- 
ation in  not  inducing  stricture  of  the  rectum  or  any 
submucous  thickening  ; and  this  difference  arises  from 
its  being  essentially  a destructive  ulceration,  no  long- 
continued  effort  at  repair  which  would  cause  perma- 
nent deposits  taking  place. 

The  appearance  of  the  ulcer  is  peculiar,  and  there 
need  be  but  little  hesitation  in  deciding  what  it  is 
when  once  it  is  fairly  established,  but  as  I have  said, 
in  the  earliest  stage,  the  most  experienced  pathologist 
may  be  at  fault. 

The  following,  from  my  observations,  I should  say 
are  the  characteristics  of  the  sore  : — the  shape  is 
usually  irregular,  I have  only  once  seen  it  quite  cir- 
cular and  symmetrical ; this  occurred  in  a case  I shall 
presently  relate.  Its  edges  are  sharp  and  cleanly  cut ; 
it  does  not  undermine  the  mucous  membrane ; it 
destroys  completely  as  far  as  it  extends ; neither  its 
edge  nor  its  base  is  at  all  hard,  and  the  mucous 
membrane  around  it  is  perfectly,  and  I may  say 
abruptly  healthy.  Its  surface  is  very  red  and  mostly 
dry;  there  is  scarcely  ever  any  amount  of  discharge 


310 


RODENT  OR  LUPOID  ULCER 


from  it.  It  sometimes  destroys  deeply,  but  its  tendency 
is  to  spread  superficially  and  to  attack  mucous  mem- 
brane rather  than  skin,  though  in  some  of  the  cases  I 
have  observed,  it  invaded  the  border-land  between 
mucous  membrane  and  skin,  and  it  may  spread  even  to  a 
considerable  distance  on  the  latter.  It  often,  for  a time, 
remains  stationary,  and  I have  noticed  repair  taking 
place  very  rapidly,  but  just  as  you  think  cicatrisation 
will  be  completed,  all  the  granulations  will  melt  away, 
like  snow  before  the  sun,  and  the  ulcer  will  appear  in 
its  former  shape  and  character  in  the  course  of  a few 
hours. 

The  patients  attacked  by  this  disease  I think  I 
may  say  are  nearly  always  of  a markedly  scrofulous 
diathesis. 

Podent  ulcer  is  generally  most  horribly  painful  (I 
have  seen  only  one  exception  to  this) ; the  sufferer 
describes  it  as  a constant,  burning,  gnawing  sensation, 
as  if  a red-hot  iron  were  applied  to  the  part.  Of  course 
the  pain  is  aggravated  when  the  bowels  act.  Death 
takes  place  from  exhaustion ; the  patient  really  appears 
to  die  from  the  never-ceasing  suffering.  Two  of  my 
cases  had  diarrhoea  towards  the  termination  of  their 
lives,  and  this  rapidly  carried  them  off.  Phthisis  was 
the  cause  of  death  in  three  others.  The  treatment 
generally  adopted  for  this  disease  has  been  the  appli- 
cation of  escharotics,  such  as  nitric  acid,  chloride  of 
zinc,  arsenite  of  copper,  the  actual  cautery,  &c.  And 
if  you  burn  the  sore  well  out  the  patient  usually  has 
for  a time  much  freedom  from  pain.  One  of  my  patients 
was  comparatively  comfortable  for  three  months  after 
the  use  of  fuming  nitric  acid,  but  of  all  escharo- 
tics I think  the  best  are  the  chloride  of  zinc  (used 


RODENT  OR  LUPOID  ULCER 


311 


after  Fell’s  plan)  and  tile  arsenite  of  copper,  but  even 
these,  in  my  experience,  will  only  delay  the  malady, 
but  do  not  cure  it.  Internal  remedies  are  advantageous, 
such  as  tonics,  cod-liver  oil,  sedatives,  &c.,  but  they 
only  lend  a feeble  help.  Specifics  are,  in  my  opinion, 
worse  than  useless.  I believe  the  only  plan  worth 
trying  now  is  exceedingly  free  incision.  Should  a 
case  come  to  me,  I should  with  my  present  knowledge 
perform  extirpation  of  the  lower  part  of  the  rectum. 
The  only  patient  I have  had  do  well  was  a Greek 
gentleman,  who  came  to  me  in  February,  1875,  and 
from  him  I removed  two-thirds  of  the  circumference 
of  the  rectum  dorsally  where  a well-marked  rodent 
ulcer  existed.  He  had  consulted  many  eminent  men, 
and  all  kinds  of  treatment  had  been  tried  internally 
and  externally  without  benefit.  The  sore  had  existed 
twelve  months  at  least  when  I first  saw  him.  I have 
excised  rodent  ulcers  before,  but  never  so  freely,  and  I 
now  think  my  operations  had  not  been  radical  enough. 
In  the  above  instance  I removed  all  the  coats  of  the 
rectum,  and  even  fat,  and  cut  at  least  an  inch  all 
round  away  from  the  sore.  When  I last  heard  of  the 
patient,  four  years  after  the  operation,  there  had  been 
no  return  of  the  sore,  and  the  patient’s  general  health 
was  very  good.  In  another  case  where  I performed 
free  excision  a year  ago  there  has  been  no  return  of 
the  growth. 

In  my  opinion  some  cases  that  occurred  to  me  years 
ago  are  so  typical,  and  illustrate  so  well  the  disease, 
that  I shall  not  relate  in  detail  any  of  later  date. 

Mrs  H — , set.  30,  a delicate-looking,  nervous,  excitable  woman,  of 
strumous  diathesis.  She  has  three  children,  the  youngest  being  two 
years  of  age.  She  has  never  had  any  miscarriages  or  any  serious  ill- 


312 


RODENT  OR  LUPOID  ULCER 


ness  prior  to  her  present  one;  but  considers  herself  as  delicate  and  suffers 
much  from  sore  throat.  Six  months  ago  she  was  supposed  to  have 
fissure  of  the  rectum,  and  an  operation  was  performed  upon  her  by  a 
very  skilful  surgeon,  but  she  did  not  get  well.  She  was  better  for  a 
time,  but  the  pain  has  returned  and  she  feels  much  as  she  did  before 
being  operated  upon. 

On  examining  her  I found  an  inflamed-looking  ulcer  at  the  entrance 
to  the  anus,  it  was  partially  external,  about  one  third  being  outside  and 
the  rest  inside.  It  was  three  quarters  of  an  inch  long  by  about  half  an 
inch  wide;  it  was  quite  superficial,  and  was  not  at  all  hard.  The 
sphincter  ani  was  spasmodically  contracted  ; she  suffered  a good  deal 
of  aching  pain,  worse  after  action,  and  the  bowels  were  very  confined. 
There  was  no  polypus.  I decided  to  divide  the  sphincter  freely.  My 
friends  Dr  Crosby  and  Mr  Shillitoe,  who  assisted  me  at  the  operation, 
were  strongly  of  opinion  that  the  sore  was  syphilitic.  I have  mentioned 
that  she  had  sore  throat,  but  she  had  no  rash,  and  there  was  no  history 
of  syphilis.  The  uterus  was  found  to  be  quite  healthy.  This  lady’s 
husband  had  not  been  a steady  man,  and  therefore  it  was  by  no  means 
certain  that  she  had  not  been  infected ; so  it  was  agreed  that  she 
should  take  the  bichloride  of  mercury  with  tonics  and  cod-liver  oil. 

The  operation  at  once  relieved  the  pain,  and  she  went  on  very  satis- 
factorily. The  wound  looked  healthy,  granulated  freely,  and  I saw  no 
reason  why  she  should  not  do  well ; but  after  about  five  weeks  the  sore 
became  stationary,  and  refused  to  answer  to  stimulating  lotions ; 
moreover,  she  began  to  suffer  from  her  old  pain,  which  she  always 
described  as  being  like  “ a red-hot  iron  applied  to  the  part.”  I may 
say  that  the  wound  had  healed  up  to  nearly  the  dimensions  it  was  when 
I operated.  I had  now  pretty  well  made  up  my  mind  as  to  the  character 
of  the  ulcer,  so,  when  at  the  end  of  three  months  I found  it  still  no 
better,  but  rather  increasing  in  size,  I determined  to  cleanly  excise  the 
whole  sore.  Again  assisted  by  the  same  gentlemen,  I freely  removed 
the  ulcer,  cutting  wide  of  it,  and  removing  the  base  fully  down  to  the 
cellular  tissue,  taking,  of  course,  nearly  all  of  one  half  of  the  external 
sphincter  muscle  away.  After  this  I well  swabbed  the  wound  with  a 
strong  solution  of  chloride  of  zinc.  Both  Dr  Crosby  and  Mr  Shillitoe 
agreed  that  it  was  impossible  by  the  incision  I had  made  not  to  have 
removed  all  the  diseased  parts.  After  this  operation  for  three  months 
the  patient  went  on  well,  and  the  sore  healed  up  to  nearly  its  original 
size,  when  it  again  halted,  and  the  pain  returned  as  badly  as  ever. 
My  colleague,  Mr  Gowlland,  now  saw  her  in  consultation  with  me,  and 
was  much  inclined  to  give  a favorable  prognosis,  but,  on  taking  the  case 
in  hand  himself,  he  soon  found  that  no  remedy  he  had  knowledge  of  was 
of  any  avail.  This  lady  afterwards  consulted  many  eminent  surgeons, 
but  without  deriving  any  benefit,  and  she  died  in  about  three  years 


RODENT  OR  LUPOID  ULCER 


313 


from  the  commencement  of  her  illness,  under  the  care  of  the  late 
Mr  De  Morgan,  in  the  Harley  Street  Surgical  Home  for  Ladies. 

A girl,  set.  17,  who  came  from  the  country,  was  taken  into  St  Mark’s 
Hospital  under  my  care  in  the  summer  of  1867.  She  was  a ruddy-com- 
plexioned,  heavy,  rather  stupid,  strumous  looking  person,  and  we  had 
a good  deal  of  difficulty  in  extracting  any  information  from  her.  She 
had  a sore  just  at  the  verge  of  the  anus,  towards  the  perineum,  and  it 
had  burrowed  through  into  the  vagina,  close  to  the  fourchette.  She 
did  not  know  how  long  it  had  existed.  She  professed  to  be  very 
innocent,  and  strongly  denied  any  possibility  of  syphilis,  but  she  had 
no  appearance  of  a hymen,  and  her  vagina  was  capacious.  She  had  a 
superficially  ulcerated  throat,  and  some  spots  of  a suspicious  character 
on  her  head  and  on  her  body.  She  had  no  enlarged  glands  in  her 
groins ; she  complained  of  a great  deal  of  pain  in  the  sore.  I made  but 
little  doubt  about  its  being  syphilitic,  and  prescribed  an  antisyphi- 
litic treatment ; finding  no  improvement  take  place,  I passed  a director 
through  the  sinus  and  laid  it  open — still  it  did  not  heal.  Mr  James 
Lane,  who  was  then  one  of  my  colleagues,  saw  it  and  agreed  with  me 
as  to  its  being  a syphilitic  sore,  so  I persevered  with  the  remedies  for 
some  time  longer,  but  it  did  not  heal,  and  I began  to  have  my  sus- 
picions that  I had  made  an  incorrect  diagnosis.  I then  treated  the 
ulcer  freely  with  strong  nitric  acid,  and  for  a time  it  greatly  improved, 
and  she  suffered  scarcely  any  pain ; and  then  all  of  a sudden,  without 
any  apparent  cause,  the  sore  spread  and  extended  up  the  bowel,  as  well 
as  the  vagina,  removing  the  tissues  rather  deeply.  She  rapidly  lost 
flesh,  became  very  weak,  and  had  almost  constant  pain,  which  was  only 
slightly  mitigated  by  hypodermic  injections  of  morphia.  I kept  her  in 
the  hospital  for  a long  while,  but  finally,  at  her  own  request,  I sent  her 
home,  and  I was  informed  that  she  did  not  live  very  long. 

A man,  set.  42,  of  delicate  and  feeble  appearance,  was  an  out-patient  of 
mine  at  St  Mark’s.  He  had  been  ill  for  about  twelve  months,  and  had 
been  in  several  hospitals.  He  had  ulceration  of  the  rectum,  superficial 
but  extensive ; dorsally  it  extended  up  the  bowel  for  quite  two  inches, 
and  laterally,  on  both  sides,  for  about  an  inch ; the  skin  externally  was 
slightly  involved ; there  was  no  constriction  of  the  bowel,  and  no 
deposits;  the  sore  had  a very  dry  and  red  appearance,  it  discharged  a 
sanious  fluid,  but  no  pus.  He  suffered  most  horribly,  scarcely  ever  had 
a moment’s  ease,  and  he  took  all  the  morphia  he  could  get.  He  would 
not  come  into  the  hospital  to  have  anything  done ; all  he  prayed  for 
was  something  to  relieve  his  pain.  I taught  him  to  use  the  hypodermic 
syringe  upon  himself,  and  he  obtained  some  ease  from  that.  When  he 
became  too  weak  to  come  to  the  hospital  I visited  him  at  home,  wishing 
much  to  be  allowed  to  examine  the  body  after  death,  but  when  that 


814 


RODENT  OR  LUPOID  ULCER 


event  occurred  his  friends  would  not  accede  to  my  request.  He  died  of 
diarrhoea ; there  was  no  evidence  of  any  secondary  deposits  having 
taken  place. 

John  S — , a gunner  in  the  Royal  Artillery,  set.  31,  was  sent  to  me  at 
St  Mark’s,  January,  1872,  from  the  hospital  at  Shoeburyness.  The 
history  is  that  he  has  been  in  India  for  six  years,  and  returned  to 
England  twelve  months  back.  While  in  India  he  had  diarrhoea,  fever, 
and  small-pox,  but  never  dysentery,  always  enjoyed  good  health  ; he  is 
a steady  man,  single,  and  of  very  good  character  in  the  army.  He 
cannot  quite  assign  any  date  to  his  rectal  affection,  but  had  piles  in 
India  and  some  operation  was  performed  for  their  cure ; after  this  he 
was  but  little  troubled  until  a few  months  before  he  returned  to  this 
country.  He  has  been  six  months  in  the  military  hospital  without  any 
improvement  in  his  condition.  He  has  never  had  syphilis,  but  has  had 
gonorrhoea. 

He  is  a middle-sized  slight  spare  man,  much  marked  by  small-pox, 
aspect  not  very  unhealthy.  An  examination  of  the  chest  detected 
dulness  at  the  upper  part  of  the  right  lung;  he  is  rather  subject 
to  cough  and  there  is  phthisis  in  his  family,  but  he  has  never  suffered 
from  haemoptysis  or  inflammation  of  the  lungs.  On  separating  the 
buttocks  a perfectly  symmetrical,  nearly  circular  sore  is  seen  extending 
all  round  the  anus,  it  is  as  large  as  a five-shilling  piece,  very  super- 
ficial, with  a well-defined  edge ; the  sore  discharges  but  little  pus,  is 
remarkably  clean  and  red,  and  is  covered  by  rather  largish  granula- 
tions. The  anus  is  more  patulous  than  natural,  and  the  ulceration  is 
found  to  extend  up  the  bowel  for  fully  an  inch  ; above  this  the  mucous 
membrane  is  quite  healthy.  There  is  not  the  slightest  induration 
about  the  sore.  The  sphincter  muscle  is  very  relaxed  and  powerless, 
and  the  patient  states  that  when  the  motions  are  loose  he  has  but  little 
control  over  them.  There  is  no  evidence  of  syphilis  ; he  has  no  rash} 
sore  throat,  or  enlarged  glands.  He  does  not  suffer  severe  pain,  but 
there  is  a constant  burning  in  the  part,  which  is  aggravated  by  any 
movement  and  by  the  action  of  the  bowels.  His  appetite  is  fair ; he 
sleeps,  but  his  nights  are  disturbed  not  actually  by  acute  pain,  but  by 
uneasiness  and  stiffness  in  the  sore.  He  has  been  gradually  losing 
flesh  and  strength. 

Many  eminent  surgeons  to  whom  I showed  this 
patient  directly  pronounced  the  sore  to  be  syphilitic, 
but  a further  investigation  induced  them  to  withdraw 
that  opinion,  and  the  majority  were  inclined  to  think 
that  it  was  rodent  ulcer.  I inoculated  the  patient  with 


RODENT  OR  LUPOID  ULCER 


315 


the  discharge  from  the  sore,  but  the  result  of  two  sepa- 
rate operations  was  negative. 

The  treatment  at  first  was  iodide  of  potassium  with 
bark  and  cod-liver  oil,  the  application  of  stimulant  and 
sedative  lotions  to  the  sore.  After  a time,  no  benefit 
resulting,  the  iodide  was  omitted  and  Donovan’s 
solution  was  administered ; this  also  seemed  to  be  of 
no  avail. 

I destroyed  a portion  of  the  ulcer  with  the  fuming 
nitric  acid,  but  no  improvement  took  place ; therefore 
I did  not  apply  any  escharotic  to  the  whole  sore. 

This  man  remained  in  the  hospital  for  about  four 
months,  and  despite  all  that  was  done  for  him  he  got 
gradually  worse.  The  pain  was  mitigated  by  sedatives, 
but  it  became  more  severe  and  almost  constant ; he  lost 
flesh  and  strength,  and  the  ulcer  increased  in  size  until 
when  he  left  it  was  just  three  inches  in  diameter ; and 
deeper  than  at  first;  it  also  had  much  extended  up 
the  rectum.  He  went  to  the  Herbert  Hospital  at 
Woolwich,  and  I heard  some  months  afterwards  from 
the  gentleman  under  whose  care  he  was  that  he  died ; 
no  post-mortem  examination  was  made. 

I am  very  strongly  of  opinion  that  I can  do  much 
more  for  the  cure  of  the  disease  now  than  I could 
when  the  above-mentioned  patients  came  under  my 
care ; my  treatment  would  be,  if  possible,  very  free 
excision  of  the  whole  of  the  diseased  portion  of  the 
bowel. 


CHAPTER  XX 


YILLOUS  TUMOUR  OF  THE  REOTUM 

This  is  a rare  but  interesting  disease.  Mr  Quain  in 
his  work  gives  the  details  of  the  only  case  that  had 
fallen  under  his  observation.  I have  now  seen  four- 
teen examples  of  this  growth — eight  in  my  own  practice, 
three  in  St  Mark’s  Hospital,  under  the  care  of  my  col- 
league, Mr  Gowlland,  one  in  my  colleague,  Mr  Alfred 
Cooper’s  practice,  and  two  under  Mr  Goodsall’s  care. 

The  leading  symptoms  may  be  stated  to  be  the 
descent  of  a tumour,  usually  on  the  bowels  acting  or 
even  when  the  patient  walks,  and  the  very  abundant 
discharge  of  a glairy  mucus  resembling  the  white  of 
an  unboiled  egg.  This  latter,  in  all  my  cases  and  in 
Mr  Gowlland’ s also,  was  the  most  prominent  symptom ; 
even  when  the  tumour  was  not  protruded  from  the 
anus  this  discharge  frequently  ran  away  from  the 
patient  without  his  having  control  over  the  escape ; it 
is  evidently  a very  great  exaggeration  of  the  normal 
secretion  of  the  mucous  membrane  of  the  rectum  by 
the  villi  which  grow  from  it  and  form  the  tumour. 

Blood  in  some  of  my  cases  was  lost  in  quantity, 
two  of  my  patients  being  quite  blanched  from  that 
cause,  but  I would  observe  that  even  the  loss  of  the 
mucus  is  a severe  drain  upon  the  constitution,  and 
shows  itself  in  the  aspect  of  the  patient.  Exceedingly 
large  arteries  may  usually  be  felt  entering  the  broad 


VILLOUS  TUMOUR  OF  THE  RECTUM 


317 


peduncle  of  the  growth.  It  does  not  appear  that  pain 
usually  attends  this  disease,  only  discomfort  arising 
from  the  protrusion  and  constant  discharge.  The 
tumour  consists  of  a lobulated  spongy  mass,  with  long 
villus-like  groups  studding  its  surface;  it  resembles 
exactly — though  the  villi  are  much  larger — the  growth 
of  the  same  name  found  in  the  bladder.  Usually  it  is 
attached  to  the  bowel  by  a stem,  broad  rather  than 
round,  and  this  appears  to  me  to  be  more  like  an 
elongation  or  dragging  down  of  the  mucous  membrane 
and  sub-mucous  tissue  than  a development.  The 
flattened  peduncle  may  be  two  or  three  inches  in  length 
or  it  may  be  short ; in  two  of  my  patients  it  was  quite 
short,  indeed,  the  tumour  itself  came  outside  but  grew 
directly  from  the  surface  of  the  bowel. 

In  cases  where  the  growth  arises  from  the  perineal 
surface,  as  a practical  point  worth  remembering,  I 
should  say  it  is  by  no  means  impossible  that  a pouch 
of  peritoneum  may  be  dragged  down  into  the  pedicle, 
and  in  such  a case  if  the  ligatures  were  applied  close 
to  the  bowel,  peritoneum  might  be  tied  up  with  it. 

When  the  second  edition  of  this  work  was  published, 
from  what  I had  seen  and  heard  I was  of  opinion  that 
these  tumours  when  removed  did  not  return.  I am 
obliged  now  to  modify  that  opinion,  as  I am  also  as  to 
the  large  losses  of  blood  occasionally  attending  them. 
I am  also  compelled  to  express  the  opinion  that  they 
may  become  malignant,  having  now  seen  two  cases  in 
which  epithelioma  replaced  the  villous  growth.  From 
a case  I have  had  I think  it  very  probable  that  these 
growths  sometimes  shed  themselves,  and  the  patient 
may  remain  well  after  this  for  a considerable  time. 
Supposing  that,  as  Mr  Cripps  thinks,  epithelioma  is 


318 


VILLOUS  TUMOUR  OF  THE  RECTUM 


a disease  of  the  follicles  of  the  rectum,  may  not  villous 
tumours  be  epithelioma  of  the  villi  ? not  so  malignant 
from  the  fact  that  it  grows  outwards  from  the  mucous 
membrane  instead  of  sinking  into  it,  and  thus  prevent- 
ing the  ready  escape  of  the  cells.  Three  of  my  cases 
I will  relate  in  some  detail  as  they  are  my  most  recent 
ones. 


Dr  D — , a physician,  came  to  me  in  September  of  1875.  He  is  sixty 
years  of  age,  a small  and  spare  man,  with  an  aspect  of  countenance 
suggesting  malignant  disease.  He  is  married  and  has  a family.  He 
says  that  for  quite  two  years  and  a half  he  has  suffered  from  piles, 
something  occasionally  protruding  from  the  anus  on  going  to  stool. 
About  two  years  since  he  began  to  lose  blood,  and  a considerable 
quantity  of  glairy  mucus  was  discharged  from  the  bowel.  The  tumour, 
for  it  was  single,  grew  rapidly  and  always  came  down  at  the  closet, 
and  occasionally  on  exertion.  It  bled  profusely,  often  half  a pint, 
at  one  action  of  the  bowel,  and  he  had  fainted  in  the  closet  from 
loss  of  blood.  On  being  returned  inside  the  sphincters  the  bleeding 
ceased.  Latterly,  i.  e.  within  the  last  few  months,  he  had  much  diffi- 
culty in  returning  it  owing  to  its  large  size,  as  it  gradually  became  as 
large  as  a man’s  fist.  It  had,  he  said,  a soft  spongy  feel,  and  the  blood 
could  be  squeezed  out  of  it  by  the  hand.  Three  weeks  back  he  found 
the  tumour  began  to  disintegrate  on  his  handling  it.  and  now  it  had  so 
decreased  that  he  could  readily  return  it  into  the  bowel.  His  health 
had  been  very  materially  failing,  he  was  weak,  often  giddy,  with  noises 
in  his  head  and  dimness  of  vision. 

I gave  him  an  enema,  and  on  going  to  the  closet  he  brought  out- 
side the  anus  a very  vascular  tumour  looking  like  a sponge,  about  the 
size  of  a large  hen’s  egg,  and  bleeding  profusely,  as  it  was  tightly  girt 
about  by  the  sphincter.  On  examining  the  bowel  I found  the  tumour 
was  connected  with  the  mucous  membrane  by  a short,  thick,  tough 
peduncle,  which  was  quite  smooth.  When  the  growth  was  with  some 
difficulty  returned  into  the  bowel,  you  could  scarcely  realise  the  fact 
that  so  large  a tumour  existed,  only  the  pedicle  could  be  felt  as  some- 
thing hard  ; it  was  attached  about  an  inch  and  a half  up  the  rectum  on 
the  left  side  and  rather  towards  the  dorsum.  The  peduncle  was  about 
the  size  of  the  forefinger  in  thickness.  On  September  22nd,  assisted 
by  Mr  Baly,  then  the  resident  surgeon  at  St  Mark’s  Hospital,  the 
tumour  being  got  well  down  I passed  a thick  double  ligature,  by  means 
of  a rectangular  needle,  through  the  pedicle,  close  to  its  attachment  to 


VILLOUS  TUMOUR  OF  THE  RECTUM 


319 


the  rectum,  and  tied  it  tightly  in  halves,  I felt  a large  vessel  pulsating 
forcibly  in  the  pedicle,  and,  of  course,  avoided  wounding  this  with  the 
needle.  The  peduncle  was  so  short  that  I did  not  dare  to  cut  off  the 
tumour,  fearing  if  I did  so  the  ligatures  might  slip.  The  growth  was 
lobulated  and  distinctly  villous. 

The  patient  made  an  excellent  recovery,  and  speedily  gained  health 
and  strength.  In  about  twelve  months  after  this  operation  Dr  D — 
again  came  to  me  and  said  the  growth  had  returned.  On  examination 
I found  he  was  right,  but  the  tumour  was  small.  This  time  there  was 
absolutely  no  peduncle,  and  it  was  broad  at  the  base  and  felt  hard  at 
its  attachment  to  the  rectum.  This  case  led  me  to  doubt  the  innocent 
character  of  villous  tumour.  I agreed  to  remove  the  growth  again, 
and  the  patient  being  placed  under  ether  I was  able  to  dilate  the 
sphincters,  and,  partly  by  knife  and  partly  by  ligature,  to  extirpate  the 
whole  very  thoroughly.  After  this  the  patient  recovered,  and  there 
had  been  no  return  up  to  a very  recent  date  when  I saw  this  gentleman. 
Seen  again  in  November,  1881.  Epithelioma  has  developed  around  the 
rectum  extending  from  the  site  of  the  old  growth. 

A young  man,  pale  and  thin,  was  sent  to  me  at  St  Mark’s  Hospital 
in  April  of  1877  by  Dr  Way,  of  South  sea.  He  said  he  had  piles,  that 
they  came  down  at  the  closet  and  on  walking  about ; they  did  not  bleed 
much,  but  he  lost  quantities  of  watery  discharge  which  frequently 
ran  away  and  saturated  his  trousers.  On  administering  an  enema  he 
strained  down  a large  tumour  the  size  of  a hen’s  egg  with  a peduncle 
broad  and  thin ; it  was  ligatured  in  four  portions  and  cut  off.  He 
made  a good  recovery,  and  left  the  hospital  in  three  weeks  quite  well. 
On  examining  the  bowel  after  the  ligatures  came  away  no  trace  of 
hardness  or  peduncle  could  be  felt ; the  tumour  was  situated  at  the 
dorsal  surface  of  the  bowel  and  to  the  right  side. 

J.  B — , set.  52,  was  admitted  into  St  Mark’s  Hospital  under  my  care 
on  the  22nd  of  April,  1878.  He  was  in  appearance  the  colour  of  old 
wax,  was  very  feeble,  and  looked  prematurely  aged.  His  heart’s  action 
was  intermittent,  and  a soft  blowing  sound  could  be  heard.  He  said 
that  he  had  suffered  from  what  he  considered  to  be  piles  for  some  years, 
but  lately  he  had  a very  large  mass  come  outside.  He  lost  quantities 
of  blood,  and  there  was  also  a discharge  from  the  bowel  “ like  gum 
water.”  He  had  a tendency  to  diarrhoea ; great  difficulty  was  experi- 
enced in  returning  the  growth  which  bled  all  the  while  it  was  pro- 
truded. On  examining  the  tumour  when  down  it  was  found  to  be  quite 
as  large  as  a man’s  fist,  spongy,  lobulated,  with  the  villi  greatly  hyper- 
trophied, the  growth  was  so  vascular  that  you  could  scarcely  touch  it 
without  arterial  blood  spurting  out.  On  passing  the  finger  into  the 
rectum  the  tumour  was  found  to  grow  all  round  the  bowel,  and  there 


320 


VILLOUS  TUMOUR  OF  THE  RECTUM 


was  absolutely  no  stem;  all  attempts  therefore  to  deal  with  it  by 
ligature  in  the  ordinary  way  could  not  be  successful.  As  an  opera- 
tion was  necessary  to  save  the  man's  life,  I determined  to  remove  the 
tumour,  and  I thought  I could  succeed  by  ligature  and  strong  harelip 
pins.  With  much  trouble  and  great  loss  of  blood  I managed  to 
strangulate  the  whokNmass.  When  I perforated  the  stump  of  the 
growth  with  a needle  threaded  with  a double  ligature  and  tied  each  way, 
the  bleeding  was  tremendous  at  the  point  where  the  segments  were 
drawn  apart,  therefore  I could  find  no  way  to  strangulate  and  arrest 
hsemorrhage  save  by  the  harelip  needles  and  the  figure-of-eight  ligature. 
The  actual  cautery  and  perchloride  of  iron  had  no  power  over  the 
bleeding  of  this  huge  cauliflower-looking  growth.  Of  course  it  had 
to  be  left  protruding  from  the  anus.  No  return  until  December,  1880, 
when  the  rectum  was  attacked  by  epithelioma,  and  the  growth  extended 
high  up.  He  died  May,  1881. 

The  patient  was  exceedingly  exhausted,  not  being 
in  a condition  to  support  such  a suddeif^loss  of  a 
quantity  of  blood.  For  a few  days  I was  in  some 
anxiety  about  the  termination  of  the  case,  but  he 
rallied  wonderfully,  and  at  the  end  of  a few  days 
I thought  him  safe  if  no  secondary  haemorrhage 
took  place;  this  fortunately  did  not  occur.  The 
decomposing  mass  was  kept  quite  sweet  by  charcoal 
powder  and  he  got  on  well ; the  parts  separated  with- 
out any  bleeding  whatever  and  left  a large  granulating 
sore ; just  as  we  thought  all  was  right  he  was  attacked 
with  diarrhoea  very  difficult  of  control,  in  fact,  nothing 
was  of  service  but  a powder  consisting  of  bismuth, 
soda,  charcoal,  and  opium,  which  eventually  cured 
him.  He  was  not  sufficiently  recovered  to  leave  the 
hospital  until  two  months  after  the  operation.  I have 
seen  this  patient  frequently  since  he  was  discharged, 
and  no  return  of  the  tumour  had  taken  place,  but  high 
up  in  the  rectum  I find  some  small  nodules  ;*  whether 

# Since  this  was  written  epithelioma  developed,  and  the  patient  died 
in  May,  1881. 


VILLOUS  TUMOUR  OF  THE  RECTUM 


321 


they  would  develop  into  anything  serious  T could  not 
for  some  time  judge,  but  I watched  him  with  interest 
and  some  anxiety.  After  the  operation  his  general 
health  became  quite  restored  and  his  appearance 
wonderfully  improved. 

I have  mentioned  my  belief  that  villous  tumours  at 
times  shed  themselves,  and  I will  relate  the  case  which 
supports  my  view — 

Miss  H — , a maiden  lady,  of  fifty  or  more  years  of  age,  was  kindly 
sent  to  me  by  Dr  Morton,  of  Kilburn.  She  was  a tall,  spare  woman 
with  a rather  worn  expression  of  face.  Her  history  was  that  about 
twenty  years  ago  she  had  suffered  from  losses  of  blood  from  the  rectum, 
and  also  from  a discharge  which  she  described  as  like  thin  starch. 
This  fluid  flowed  away  at  times  in  abundance.  At  this  time  her 
health  was  much  broken,  she  had  pains  in  her  back  and  inability  to 
take  exercise ; nothing  came  down  on  the  bowels  acting.  Her  bowels 
were  very  constipated  and  she  took  some  strong  aperient  pills,  the 
result  being  that  when  the  bowels  acted  “ a large  mass  of  flesh  came 
away,  and  the  bleeding  was  so  severe  that  she  fainted.”  After  this  she 
had  no  more  bleeding  or  watery  discharge,  and  quickly  recovered  her 
health.  After  being  well  until  about  twelve  to  fifteen  months  ago,  to 
her  horror  the  bleeding  and  discharge  recommenced.  She  consulted 
medical  men,  who  said  her  case  was  one  of  piles,  and  various  treatment 
was  adopted  without  any  effect.  She  told  me  that  portions  of  a fleshy 
soft  character  came  away  sometimes  at  stool.  She  had  straining,  pains, 
and  general  debility.  She  was  ordered  to  take  charcoal,  bismuth,  and 
soda  powders  three  times' in  the  day,  and  use  an  injection  of  rhatany. 
I requested  her  to  send  me  a specimen  of  what  she  passed  when 
straining.  My  examination  detected  nothing  but  a relaxed  voluminous 
mucous  membrane  which  came  rather  down  into  the  rectum,  but 
neither  by  finger  nor  speculum  could  I detect  any  disease.  In  a few 
days  after  the  consultation  the  patient  sent  me  some  of  the  discharge 
and  I found  remarkably  good  specimens  of  villous  growth,  some  pieces 
being  as  large  as  a hazel  nut.  I saw  this  lady  once  more,  and  used  all 
means  to  see  or  feel  the  growth,  but  could  not  get  at  it.  I was 
quite  sure  of  my  diagnosis  and  could  only  tell  her  I hoped  in  time 
the  stem  of  the  growth  would  increase  in  length  and  come  down 
within  reach,  so  that  one  could  remove  the  disease.  A few  months  after 
this  I had  a letter  informing  me  that  the  charcoal  had  caused  a stoppage 
in  the  bowels,  for  which  large  doses  of  aperients,  castor  oil  among  them, 

21 


322 


VILLOUS  TUMOUR  OF  THE  RECTUM 


Lad  been  used  to  obtain  relief,  and  that  when  action  was  at  length 
obtained,  a mass  came  away  not  so  large  as,  but  much  resembling  the  one 
she  Lad  passed  years  ago,  and  that  she  felt  much  relieved.  She  sent 
me  a portion  of  the  specimen,  and  that  sure  enough  was  a villous 
growth.  Whether  there  will  be  any  further  return  remains  to  be 
seen. 

The  case  is  a very  interesting  one,  and  leads  me  to 
think  that  villous  growths  may  break  away  from  the 
bowel  more  often  than  is  supposed,  and  I remember 
some  very  puzzling  cases  I have  seen  which  were 
possibly  similar  to  the  one  I have  related. 


CHAPTER  XXI 


MISCELLANEOUS 

In  this  my  concluding  chapter  I intend  to  treat 
briefly  of  several  forms  of  disease  of  the  rectum,  which 
are  of  somewhat  rare  occurrence. 

Neuealgia  of  the  Rectum 

I can  see  no  reason  why  neuralgia  should  not  some- 
times attack  the  rectum  as  well  as  any  other  part  of 
the  body ; no  doubt  many  other  affections  have  been 
erroneously  called  neuralgic,  and  I am  ready  to 
confess  that  I have  more  than  once  considered  pains 
as  neuralgic  which  I later  on  discovered  to  originate 
from  a lesion  of  structure. 

Very  slight  erosions  or  even  inflammation  of  a spot 
in  the  rectum  may  set  up  much  pain ; and  at  the  same 
time  be  so  difficult  to  discover  as  to  baffle  the  closest 
and  most  searching  investigation. 

I have  been  in  the  habit  of  calling  pain  in  the 
rectum  or  sphincter  muscles  neuralgic  when  I have 
not  been  able  to  find  out  the  slightest  lesion,  sign  of 
inflammation,  or  discharge  of  any  kind,  and  where  the 
pain  was  not  aggravated  by  action  of  the  bowels  ; this 
I always  consider  an  important  point  in  diagnosis. 

In  my  cases  the  pain  has  been  at  times  severe,  at 


324 


NEURALGIA  OF  THE  RECTUM 


others  absent,  and  only  in  two  instances  was  it 
constant.  The  patients  have  been  mostly  delicate, 
irritable,  or  nervous  people,  who  have  been  subject  to 
neuralgic  pains  in  other  parts.  I have  noticed  the 
attack  follow  direct  exposure  to  wet  and  cold  by 
sitting  upon  damp  grass.  One  attack  predisposes  to 
another ; several  times  in  private  practice  I have  been 
consulted  by  the  same  patient. 

Usually  you  will  find  in  these  cases  general  debility, 
but  in  addition  disorders  of  the  digestive  organs  ; very 
often  the  liver  is  much  affected ; it  will  therefore  not 
do  to  commence  your  treatment  with  tonics  and  anti- 
neuralgic  remedies ; first  of  all  unload  and  put  the 
abdominal  viscera  into  condition,  and  then  quinine, 
iron,  strychnia,  and  hypodermic  injections  of  morphia 
may  at  once  cure  your  patient.  Attention  to  this 
point  is  all  important ; in  some  instances,  however,  one 
has  to  confess  to  an  inability  to  do  more  than  tempo- 
rary good ; nothing  appears  to  cure  the  malady. 

When  the  pain  seems  quite  confined  to  the  sphincter 
muscle  there  is  always  spasmodic  contraction,  and  I 
believe  forcible  dilatation  of  the  anus,  performed  as  I 
have  before  described,  to  be  the  best  treatment ; after 
this  is  done  a hypodermic  injection  of  morphia  will 
often  cure  this  affection,  which  I used  to  consider  a 
very  intractable  form  of  myalgia. 

There  are  other  nervous  diseases  of  the  rectum 
described  by  authors,  but  they  are  very  rare  indeed ; 
one  of  them,  which  is  called  “ irritable  rectum,”  I 
think  is  really  the  result  of  a chronic  inflammation  of 
the  mucous  membrane,  as  in  such  cases  I have 
observed  much  heat  in  the  bowel  and  tenesmus,  as  well 
as  a discharge  of  mucus.  These  cases  are  best  treated 


REMOVAL  OF  COCCYX 


325 


by  very  gentle  laxatives  to  keep  the  bowels  acting,  by 
alkalies  with  bitter  infusions,  and  by  insufflation  of 
bismuth  and  charcoal  into  the  rectum.  This  treatment 
will  soon  allay  the  irritability,  and  after  this  is  accom- 
plished the  cure  will  be  rendered  permanent  by  injec- 
tions of  rhatany  and  starch,  with  small  doses  of  the 
liquid  extract  of  opium. 

Removal  of  Coccyx 

I have  seen  many  female  patients  suffering  from 
what  has  been  considered  neuralgic  pain  in  the  rectum, 
but  really  the  pain  was  most  distinctly  referable  to  the 
sacro-coccygeal  joint.  These  are  most  intractable 
cases,  and  on  four  occasions  I have  removed  the 
coccyx  in  the  hope  of  curing  the  disease  which  was 
wearing  out  the  mind  and  body  of  the  patients. 

My  first  case  was  a married  woman  set.  54,  with 
seven  children.  She  had  for  years  been  complaining 
of  pain  in  the  rectum  and  at  the  end  of  the  spine,  which 
rendered  her  quite  incapable  of  performing  her  house- 
hold duties.  She  could  not  sit  down  except  on  a 
ring-shaped  air-cushion,  and  when  from  home  she 
always  wore  under  her  dress  a couple  of  pads  to  catch 
the  buttocks  so  that  the  end  of  the  spine  should  not 
touch  anything. 

If  the  bowels  were  confined  she  had  great  pain 
before  and  at  the  time  of  their  acting  rather  than 
afterwards.  If  she  stooped  and  suddenly  raised  her- 
self, the  pain  c<  was  like  a knife  going  through  the  very 
bottom  of  the  back.”  She  could  walk  but  a short  dis- 
tance, and  going  upstairs  was  a very  painful  exertion 
to  her. 


326 


REMOVAL  OF  COCCYX 


On  examining  the  rectum  no  fissure  or  ulcer  was 
discoverable,  but  when  the  finger  was  pressed  on  the 
coccyx  so  as  to  move  it — and  it  moved  exceedingly 
freely  and  easily — she  complained  most  bitterly. 

As  nothing  I could  do  seemed  to  benefit  her,  and 
she  had  been  under  many  eminent  physicians  and  sur- 
geons without  getting  better,  I determined  to  remove 
the  coccygeal  bone  at  the  joint  ; and  this  I did. 
Making  a straight  vertical  incision  along  the  bone,  and 
taking  care  not  to  wound  the  rectum,  I dissected  it 
out  and  disarticulated  it  without  any  difficulty.  There 
did  not  appear  to  be  any  appreciable  pathological 
change  in  the  bone.  The  wound  healed  rapidly,  and  I 
was  much  pleased  to  find  that  the  patient  was  cured. 
She  was  able,  nine  months  after  the  operation,  to 
sit  down  in  comfort,  and  to  walk  about  without  any 
pain. 

Encouraged  by  this  success  I operated  some  years 
back  in  a very  similar  case  at  St  Mark’s  Hospital.  The 
patient  was  an  unmarried  woman,  32  years  of  age,  who 
had  been  for  years  suffering  from  pains  in  the  rectum 
and  end  of  the  spine.  Her  symptoms  were  almost 
precisely  like  those  I have  described,  and  there  was  no 
lesion  in  the  bowel,  but  she  had  an  intussusception, 
not  to  any  great  extent,  of  the  rectum.  This  made 
me  less  sanguine  of  success,  but  as  the  pain  was  un- 
doubtedly sacro-coccygeal  I removed  the  bone  and  the 
wound  healed  well.  Although  she  is  not  perfectly 
free  from  pain  she  can  sit  down  in  comfort,  which  she 
could  not  do  at  all  before,  and  in  many  other  respects 
she  is  improved. 

Two  years  ago  I removed  the  coccygeal  bone  from 
a gentleman  who  had  sustained  a most  painful  injury 


INFLAMMATION  OF  THE  RECTUM 


327 


by  falling  on  the  side  of  a rowing  boat  from  which  he 
was  getting  out.  He  had  suffered  much  afterwards, 
and  a fistula  formed  in  the  bowel.  This  had  been 
opened  but  he  was  no  better — when  he  began  to  get 
about  the  pain  returning  in  all  its  previous  acuteness. 
On  carefully  examining  him  I found  that  a sinus  ran 
close  to  the  coccyx,  and  bare  bone  could  be  detected 
with  the  probe,  so  no  doubt  a periosteal  abscess  had 
formed.  Believing  the  bone  to  be  diseased  I requested 
him  to  allow  me  to  remove  it,  and  he  consented. 
When  the  bone  was  excised  there  was  not  any  necrosis 
evident,  but  it  was  unusually  dense,  so  I concluded 
inflammation  had  been  present.  I was  rather  in 
doubt  about  the  case  doing  well,  but  a perfect  recovery 
was  the  result,  all  pain  being  gone  before  the  wound 
had  healed. 

I by  no  means  intend  to  advocate  the  frequent 
removal  of  the  coccyx  for  pains  in  the  neighbourhood 
of  that  bone,  yet  I think  in  some  cases  where  all  other 
means  have  been  exhausted,  and  there  is  good  evidence 
that  the  pain  is  induced  by  every  movement  of  the 
bone,  its  excision  is  called  for  and  may  be  the  means 
of  curing  an  otherwise  incurable  disease.  I do  not  see 
any  particular  danger  in  the  operation,  and  that  the 
coccyx  may  be  dispensed  with  without  any  evil  resulting 
is  I think  certain. 

Inflammation  of  the  rectum  may  occur  in  both  a 
chronic  and  acute  form.  The  chronic  variety  obtains 
in  old  people.  The  symptoms  are  a sensation  of  heat 
and  fulness  in  the  rectum,  frequent  desire  to  go  to 
stool,  and  great  tenesmus  ; there  may  be  a discharge 
of  blood  and  mucus.  With  these  symptoms  you  would 


328 


INFLAMMATION  OF  THE  RECTUM 


suspect  impaction,  but  a digital  examination  will  settle 
that  point.  Injections  of  starch  and  opium  are  very 
beneficial,  but  I think  in  the  aged  the  most  efficient 
medicines  are  turpentine,  aloes,  confection  of  black 
pepper  and  copaiba.  I usually  order  frequent  and 
small  doses  of  Barbadoes  aloes ; it  acts  as  a stimulant 
to  the  rectum,  induces  a healthy  action,  and  very  soon 
the  disorder  subsides.  Hamamelis  is  another  useful 
remedy;  it  is  in  fact  rapidly  curative  in  some  cases. 
It  may  be  used  as  an  injection  and  also  administered 
by  the  mouth. 

Acute  inflammation  of  the  rectum  resembles  dysen- 
tery in  its  symptoms,  but  it  is  distinguished  from  it  by 
the  absence  of  abdominal  pain  or  tenderness  and  severe 
constitutional  disturbance ; the  pain  is  generally  con- 
fined to  the  sacrum  and  perineum  ; the  bladder  is  often 
sympathetically  affected,  and  there  is  not  infrequently 
difficulty  in  passing  water. 

The  most  effective  treatment  would  be  leeches 
around  the  anus,  hot  baths,  injections  of  water  in  small 
quantity  as  hot  as  can  be  borne,  to  this  may  be 
added  a drachm  of  Battley’s  sedative.  A hot  bath 
followed  by  a hypodermic  injection  of  morphia  is  likely 
to  benefit.  The  patient  should  keep  the  recumbent 
position,  take  very  light  unstimulating  nourishment, 
and  no  irritating  purges  should  be  given.  If  it  be 
necessary  to  relieve  the  bowel  of  its  contents  a flask  of 
warm  olive  oil  as  an  enema  is  the  best  that  can  be 
employed.  I have  seen  very  few  such  cases  in  this 
country,  but  they  are  not  so  uncommon  in  hot 
climates. 


INDEX 


PAGE 

Abscess,  a cause  of  fistula  . . 13 

— formation  of,  after  operation 

on  fistula  . . . . .51 

Acid,  nitric,  applied  to  internal 
haemorrhoids  ....  113 

— — applied  to  procidentia  recti  165 
Acorns,  powdered,  for  diarrhoea  of 

procidentia  . . . .172 

Actual  cautery,  used  by  native 
doctors  for  cure  of  piles  . . 1 

Anal  fistula  . . . . .18 

Anus,  eczema  of  . . . . 184 

— itching  of  ...  182 

Arterial  haemorrhoids  . . .91 

Artificial  anus  (see  colotomy) 

Ascarides,  a cause  of  pruritus  ani  . 190 

Bladder,  diseases  of,  complicating 


haemori’hoids  ....  107 
Bleeding  from  rectum  after  opera- 
tions on  fistula  . . . .46 

— on  piles  ....  151 

Blind  external  fistula  . . .18 

— internal  fistula  . . .18 

Bone  stud  for  cure  of  fistula  . 27 

Cancer  of  rectum . . . .269 

— colotomy  in  . . . . 299 

— complicating  haemorrhoids  . 148 

— duration  of  life  in  . . 269 

— ordinary  site  of  . . 272 

— question  of  heredity  in  . . 270 

— treatment  of.  . . . 277 

— varieties  of  . . . . 271 

Capillary  haemorrhoids  . . 90 

— treatment  of . . . .98 

Carbolic  acid,  injection  of,  into 

haemorrhoids  ....  117 
Caustic  pastes  applied  to  internal 
haemorrhoids  ....  115 
Cauterisation,  linear,  for  internal 
haemorrhoids  ....  120 

— ponctuee,  for  internal  haemor- 
rhoids   119 


PAGE 

Cautery,  galvanic,  for  internal  hae- 
morrhoids ....  125 

— Paquelin,  for  internal  haemor- 
rhoids   125 

Chancroid  as  a cause  of  rectal  ul- 
ceration .....  252 
Chian  turpentine,  its  uselessness 
in  cancer  of  the  rectum  . . 277 

Children,  polypus  recti  in  . . 173 

— prolapsus  recti  in  . . . 163 

Clamp  and  scissors  for  removal  of 

haemorrhoids  ....  126 
Coccyx,  removal  of  325 

Coexistence  of  fistula  with  phthisis  56 
Colloid  cancer  of  the  rectum  . 271 
Colotomy  in  cancer  of  the  rectum  299 
Complete  fistula  . . . .18 

Concretions  in  the  rectum  . . 220 

Contraction  of  bowel  after  opera- 
tions for  haemorrhoids  . . 141 

Cough,  as  influencing  success  of 
operation  for  fistula  in  ano  in 
phthisical  patients  . . .67 

Crushing  instrument,  author’s,  for 
treating  internal  haemorrhoids  . 131 

Diagnosis  of  rectal  diseases  . . 2,  5 

Digital  exploration  of  rectum  . 7 

Dilatation  of  sphincters  . . 8 

— for  cure  of  fissure  . . 209 

of  haemorrhoids  . . 127 

Drainage-tubes,  use  of,  after  opera- 
tion for  fistula  . . . .17 

Drinkers,  preparatory  treatment 
before  operating  on  . . .6 

Dysentery,  a cause  of  stricture  of 
the  rectum  . . . .251 

Ecraseur,  the,  for  removal  of  hae- 
morrhoids . . . .112 

Eczema,  a cause  of  pruritus  ani  . 184 
Elastic  ligature  for  cure  of  fistula  29 
Encephaloid  cancer  of  rectum  . 271 

— case  of  . . . . . 278 


330 


INDEX 


PAGE 

Epithelioma  of  rectum  . . . 271 

Eversion  of  rectum,  how  to  effect . 11 

Examination  of  patients,  how  to 
conduct 5 

— suffering  from  fistula  or  sinus  19 

Excision  of  internal  haemorrhoids  110 
Exploration  of  rectum  ...  7 

— of  haemorrhoids  . . .74 

External  fistula,  forms  of  . .18 

Extirpation  of  portions  of  rectum 


for  cancer 

. 280 

cases  of 

. 284 

Faecal  impaction  . 

. 213 

Fissure  of  the  rectum  . 

. 191 

— cause  of  pain  in  . 

. 206 

— diagnosis 

. 194 

— method  of  operating  for 

. 202 

— nervous  symptoms  connected 

with 

. 204 

— symptoms  of 

. 192 

— treatment  of. 

. 196 

by  dilating  the  sphincters  210 

— — by  dividing  the  sphincters  197 

— uterine  disease  coexisting  with  195 

Fistula  in  ano,  blind,  external  . 18 

internal  . . . .18 

— cases  of  cure  without  cutting  26 

— cases  of  spontaneous  cure  of . 24 

— causes  of  . . .13 

— complete  . . . .18 

— complicating  haemorrhoids  . 147 

— dangerous  kinds  of  . .22 

— difficult  cases  of  . . .53 

— haemorrhage  after  operations 

on 46 

— horse-shoe  form  of  . .21 

— in  conjunction  with  phthisis  . 56 

— internal  aperture  of,  how  to 

find 20 

— operations  on  . . .37 

— prevalence  of,  statistics  of  4, 12 

— treatment  of,  by  cutting  . 37 

by  the  elastic  ligature  . 29 

subsequent  to  operation  . 49 

Fistulae  and  sinuses  in  phthisical 
patients,  peculiarities  of  . .70 

Forcible  dilatation  of  sphincters 
for  cure  of  fissure  . . . 210 

— for  cure  of  haemorrhoids  . 127 

— of  stricture  of  the  rectum, 

cautions  regarding  . . .10 

Galvanic  cautery  for  internal  hae- 
morrhoids ....  125 
Glycerine  in  the  treatment  of  hae- 
morrhoids ....  108 


PAGE 

Gouty  patients,  precautions  in 
operating  on  . . .6 

— pruritus  ani  occurring  in  . 188 


Haemorrhage  after  application  of 
nitric  acid  ....  166 

— operations  on  fistula  . . 46 

on  haemorrhoids  . . 151 

treatment  of  . . 157 

Haemorrhoids,  classification  of  . 73 

— complications  of  . . . 146 

— external,  causes  of  . . 75 

diagnosis  and  symptoms  of  76 

treatment  of  . . .79 

— internal,  cases  of  . . .96 

causes  of . . . .83 

views  of  French  au- 
thors concerning  . . .84 

constitutional  treatment 


for 103 

cure  of,  without  operation  103 

dangers  resulting  from 


losses  of  blood  from  . 

. 97 

in  pregnant  women  . 

. 93 

operations  on  . 

. 109 

structure  of 

. 90 

symptoms  of  . 

. 89 

varieties  of 

. 88 

— prolapsed 

. 161 

— protruded,  how  to  replace 

. 100 

Hernia  of  bowel  complicating  pro- 
cidentia recti  ....  168 
Horse-shoe  fistula  . . .21 

Hospital,  St  Mark’s,  analysis  of 
4000  cases  at  . . . .3 


Impaction  of  faeces  . . . 213 

— cases  of  ....  214 

— causes  of  ...  214 

— complicating  haemorrhoids  . 148 

— treatment  of . . . . 218 

Incontinence  of  faeces  after  opera- 
tion for  fistula  . . . .47 

— occurring  in  procidentia  . 168 
India-rubber  ligature,  author’s 

probe  and  canula  for  passing  . 35 

— for  fistula  in  ano  . . .29 

— Professor  Dittel’s  method  of 

introducing  . . . .34 

Inflammation  of  rectum  . . 327 

— a cause  of  stricture  . . 264 

Injection,  use  of,  when  examining 

patients 7 

Instrument  for  applying  oint- 
ments to  the  rectum  . . 259 

Introduction  of  hand  and  arm  into 
intestine 9 


INDEX  331 


PAGE 

Intussusception  of  the  rectum  . 162 
Irritable  ulcer  of  the  rectum  . 191 

Itching  of  the  anus  . . . 182 

Ligature,  elastic,  treatment  of  fis- 
tula by  the  . . . .29 

— treatment  of  internal  haemor- 
rhoids by  the  ....  133 

— statistics  of  . . . 142 

Liver,  examination  of,  in  cases  of 

rectal  disease  ....  6 

Luke,  Mr,  tourniquet  for  fistula 

in  ano 43 

Lupoid  ulcer  of  the  rectum  . 308 

Mortality,  smallness  of,  after  liga- 
ture of  haemorrhoids  . . 143 

Neuralgia  of  the  rectum  . . 323 

Nitric  acid  applied  to  internal  hae- 
morrhoids. . . . 98,  113 

— applied  to  procidentia  recti 

in  children  ....  165 

Obstruction  of  rectum  from  cancer  274 

— from  impacted  faeces  . . 251 

Ointments,  instrument  for  apply- 
ing to  rectum  ....  259 

Operations  on  cancer  of  the  rec- 
tum   278 

— on  fistula  in  ano  . . .37 

— — after  treatment  of  . .49 

— on  internal  haemorrhoids  . 109 

— on  phthisical  patients  suffer- 
ing from  fistula  . . .60 

Opium  for  relief  of  cancer  of  rec- 
tum ......  276 

Pain,  question  of,  after  ligature 
of  haemorrhoids  . . . 140 

Painful  ulcer  of  rectum  (see  Fis- 
sure). 

Paquelin  cautery  for  cure  of  pro- 
cidentia   169 

Parturition,  injuries  during,  a 
cause  of  ulceration  of  the  rec- 
tum   251 

Pathology  of  internal  haemorrhoids, 
Verneuil’s  views  regarding  . 84 

Pelvic  fistula  ....  9 

Phthisis  as  a complication  of  fis- 
tula   56 

Piles  (see  Haemorrhoids). 

Pollock,  Mr  George,  on  treatment 
of  haemorrhoids  by  crushing  . 130 
Polypus  recti  ....  173 


PAGE 

Polypus  recti,  cases  of  . 

178 

— complicating  fissure 

195 

haemorrhoids  . 

150 

— treatment  .... 

180 

— varieties  .... 

174 

Procidentia  recti  .... 

161 

— causes  of  ... 

163 

— in  children  .... 

163 

— treatment  .... 

164 

by  actual  cautery 

167 

— — by  removing  portions  of 

mucous  membrane 

167 

Prolapsus  ani  (see  Procidentia). 

Pruritus  ani  .... 

182 

— accompanied  by  haemorrhoids  190 

— causes  

182 

— due  to  ascarides  . 

190 

— treatment  .... 

185 

— varieties  . . . . 

184 

Rectal  abscess,  leading  to  fistula  . 

13 

treatment  of  . 

15 

— diseases,  causes  of 

1 

prevalence  in  foreign  coun- 

tries ...... 

1 

statistics  of,  at  St  Mark’s 

Hospital 

3 

Rectum,  cancer  of 

269 

— concretions  in 

220 

— examination  of 

7 

— extirpation  of,  for  cancer 

280 

— fissure  of  ... 

191 

— inflammation  of  . 

327 

— neuralgia  of  . 

323 

— polypus  of 

173 

— prolapsus  of  . 

161 

— rodent  ulcer  of 

308 

— ulceration  and  stricture  of  . 

223 

— villous  tumour  of  . 

316 

Recumbent  position  after  opera- 

tions on  haemorrhoids  . 

138 

Removal  of  coccyx 

325 

Retention  of  urine  after  operation 

on  internal  haemorrhoids  . 

141 

— due  to  impaction  of  faeces 

217 

Salmon,  Mr,  method  of  operating 

for  fistula . . . . . 

41 

Sarcotome,  Dr  Hollis’s 

31 

Scirrhus  of  rectum 

271 

Scissors  and  director,  author’s, 
for  operating  on  fistula  in  ano  38,  42 
Scrofula,  a cause  of  ulceration  of 

rectum 250 

Sinuses,  necessity  for  dividing  all, 
in  operating  for  fistula  . . 39 

Soft  polypus  of  the  rectum  . . 174 


332 


INDEX 


PAGE 

Spasm  of  sphincters  after  opera- 
tions, how  to  prevent  . . 136 

Speculum  ani,  kinds  and  use  of  . 8 

Sphincters,  dilatation  of  .8 

for  cure  of  fissure  . . 210 

haemorrhoids  . . . 127 

Statistics  of  coexistence  of  fistula 
with  phthisis  . . . .58 

— with  rectal  diseases  . . 3 

Strangulation  of  protrusion  in 

cases  of  procidentia  . . 171 

Stricture  of  the  rectum  . . 223 

— without  ulceration  . . 263 

Syphilis,  a cause  of  fissure  of  the 

rectum 193 

— of  stricture  of  the  rectum  . 252 

Tetanus  after  ligature  of  haemor- 
rhoids   142 

Tuberculosis  a cause  of  ulceration 
of.the  rectum  ....  250 
Tumour,  villous,  of  the  rectum  . 316 

Ulcer,  painful  (see  Fissure). 

Ulcer,  rodent,  of  the  rectum  . 308 
Ulceration  and  stricture  of  the 

rectum  . . . . 223  j 

— linear  rectotomy  for  . . 237 


PAGE 

Ulceration  and  stricture  of  the 
rectum,  opinions  as  to  venereal 
causations  ....  252 

— statistics  of  seventy  cases  of  . 230 

— symptoms  of  . . . 224 

— treatment  . . . .258 

— twenty-nine  cases  of,  in  pri- 
vate practice  ....  239 

Urine,  necessity  for  examining 
before  operation  ...  6 

— retention  of,  after  operations 

on  haemorrhoids  . . . 141 

— — due  to  impaction  of  faeces  217 
Uterine  diseases  complicating  fis- 
sure ......  195 

— haemorrhoids  . . . 104 

Uterus,  state  of,  as  affecting  rec- 
tal diseases  ....  6 

Venous  haemorrhoids,  description 

of 92 

Verneuil,  Prof.,  views  of,  as  to 
causation  of  internal  haemor- 
rhoids   84 

Villous  tumour  of  the  rectum  . 316 

“ White  piles  ” . . . . 104 


PRINTED  BY  J.  E.  ADLARD,  BARTHOLOMEW  CLOSE. 


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